epidural monitering policies

[canoehead, BSN, RN]

I wonder if anyone would be willing to share their policies for monitering surgical patients on M/S with an epidural for pain control. Our policy currently states they must be woken hourly (!) and of course that isn't done. We are revising the policy and need information on the standard of care. I've done a web search but not found a lot. Can anyone help?

Thanks.

[pebbles, BSN, RN]

Epidurals that have a local anaesthetic and narcotic (We use ropivicaine and hydromorphone): BP, P, RR, CWCM, Level of pain monitored q1/2 hr x 2hrs. Then BP, P, CWCM q2 hrs for 12 hrs, then q4h for the duration of the epidural. RR monitored every hour for 24 hrs, then q4h for the duration.

Of course, to check cwcm, you have to wake the pt up, ask them about numbness to lower extremities or circumoral numbless, etc. But after 14 hours with a stable epidural, they get more rest. And the better pain control is worth it.

Epidurals without the hydromorphone you have to worry less about the RR, but we generally follow the same protocol regardless. Low BP is our most common complication. Our anaesthesiologists are pretty good about being there to help out or at least on the phone all the time to give orders. Epidurals are a lot of work for teh nurses, but they are great for the pt's (when they work, that is!)

Do you monitor every hour for the duration of the epidural?

[P_RN, ADN, RN]

Almost what Pebbles said.

Bupivicaine and Fentanyl (Most often) using a Bard pump with a basal and a PCA mode with q 1h maximum limits......

VS q 30 x2 then q 1h while the Epidural is in.

RR q 1h for the next 18 hours after removed and VS q 4h for the full 48 h post op. and yes they're waked q 1h for sensation, nausea, pain level, ITCHING!......but EPIDURALS are GREAT.

Most patients went right to Oxycontin q 12h w/ one Tylox prn q4 for breakthrough... which was hardly ever needed.

[sharann, BSN, RN]

These patients should all be on apnea monitors, even the one's without the narcotics. Marcaine can cause resp depression! Waking them up every hour is cruel and unecessary. Who thought that one up? Of course you should assess the pt Qhour for RR, and do Q 4 VS etc...

[canoehead, BSN, RN]

That's what my thinking was- what's the use of pain control if you still need to wake them every hour? We could do RR q1h, and then assess pain, nausea etc while awake. I generally think that pts are at an acceptable pain level if they are sleeping unless they tell me otherwise.

[pebbles, BSN, RN]

Agree, Canohead.

But apnea monitors? Way too high-tech and expensive where I work. Med surg, 6-7 pt's per nurse. I can make sure someone has a good RR without waking them up and without needing a fancy monitor. During the night when we have less staff around, all epidurals are inserted in PACU where they have 1:1 monitoring until the epidural is well established. If I can't look in on a pt often enough for me to feel safe with monitoring, I notify supervisor... often teh anaesthsiologist will stay with the pt for a while after the epidural is first established, anyway.

BP is still important, as well as loss of sensation... but in a well established epidural, these parameters are usually okay to monitor less often.