Post-op care of pt's with epidural

[nbnurse95]

Hi, Just wondering how pt's with epidurals for post op pain management are cared for in your hospital.

I work on a surgical unit with many ortho and abdominal surgeries. We have a room with 3 beds which is our "concentrated care" room. Right now our policy states that when a pt comes to us post op with an epidural, one RN must be assigned to that room. She can have up to 3 pt's with epidurals. She can not have other pt's and must be replaced by another trained RN when she goes to break or has to leave the room for more than a few minutes. The level of nursing care changes according to the anesthetist, ie: the RN may be able to go to break without being "replaced" in the room the next day and may have other pt's the day after that. (this room is on a reg surgical unit and the other RN's can just cover this room while you're on break).

V/S are BP, P, R, T, SpO2 q 1/2 hr for 2 hrs, then q1hr for 8 hrs, then all V/S q4hrs and R, and SpO2 q1h until the epidural is stopped. Of course neuros, pain management, sedation are checked qh. And when there's an increase in epi rate these vitals are more often.

I understand that in some hospitals these pt's come on the reg surg unit and is a part of your reg team of pts. What I'm wondering is, do you have epidurals as part of your reg load or do you have a room similar to the one I describe? This nursing shortage is making it extremely difficult to staff the floor adequately because no matter what, an RN HAS to be in our concetrated care room when fresh epidurals are admitted. This leaves the rest of the RNs with a very heavy workload.

[Fiona59]

Fresh post-ops with epidurals are returned just like any other patient. There is no dedicated nurse. Their vitals post op are routine. Then q4h to monitor pain control along with a check on the epidural site.

On my unit epidural patients are assigned to the vacant bed so they are cared for either by an LPN or RN.

Two nurses to increase the dose or change the bag for signature purposes.

I've just noticed you practice in Canada. Where? This would never fly in my hospital out here in Alberta.

[nbnurse95]

Hi Fiona59,

Thanks for the information.

I work in New Brunswick. I think our policy is going to change soon. I doubt that many hospitals have the same policy we do.

[veronica butterfly, ADN, RN]

Pt's with epidurals are just part of our regular patient load. Only difference I've seen is that some of them are on a continuous pulse oximeter for awhile after surgery, and that we're very careful when moving the patient about. If the pt is having poor pain control, we call the anesthesiologist to come and increase the dose.

[Fiona59]

The protocol in the patient chart lets us adjust the rate within specific parameters.

The gasman comes when paged if the pain control is ineffective. He will also do rounds on patients with epis.

[RN1989]

Down here in the US, epidural patients are on the regular floor with a regular load.

Some of the hospitals I have been in have great policies and orders that allowed us to increase/decrease the basal rate according to pain needs, respiratory slowing or numbness. 2 nurses who had completed the competency requirements must verify and sign any change in basal rate, wastage, changing to a new bag. We were trained to repair broken epidural caths also. We were allowed to give some prns according to protocol orders for itching, nausea, breakthrough pain with PT not responsive to prn dosing of the med.

Generally any increase in the rate required doing q30 vs for a couple of hours and then back to q4. They may or may not be on a pulse ox depending on anesthesia's preference.

Other facilities I have been in had epidurals on the floor like any other but we had to call anesthesia for EVERYTHING. They didn't even want the nurses changing the bag of meds out of the machine.

Frankly, the facility that had all the training and protocols for us to use had much better outcomes with their patients. All the nurses were required to have the competency checkoff after going to a hands on class. The nurses were well versed in the care and it was second nature - like taking vitals. The patients did much better postop and we were able to get them up and ambulating the same evening of surgery.

The facility's with the more restrictive policies had nurses that freaked out when an epidural came to the floor. They were afraid to ambulate the pts, turn them, or call anesthesia for better pain control. I saw more issues with ileus, atalectasis/pneumonias, and DVTs in those facilities due to the poorer training and care of the patients.

[nbnurse95]

Depending on the Dr's orders, we can change the epi rate according to the pt's pain or sedation within certain parameters. We can change the bag etc. We also remove the catheter when the epi is d/c'd (2 RN's must check that the catheter tip is intact.)

Thanks for the responses, I really appreciate it.

[litbitblack, ASN, RN]

We didn't get very many but when we did vs were q4 with cont pox and site check q4. you had to go to the class but could make adjustments per protocol. we only really had one problem and I think it was because someone gave lovenox( a big no no)

[nbnurse95]

We usually give heparin s/c to our post-ops. If they have an epidural, we have to withhold the heparin for 2 hrs after removal of the catheter.

[veronica butterfly, ADN, RN]

We usually give heparin s/c to our post-ops. If they have an epidural, we have to withhold the heparin for 2 hrs after removal of the catheter.

Our main general surgeon always wants us to give the sub-q heparin... She is smart as a whip and wonderful doc, however, I always document that I spoke to her and she wants the heparin given. ALWAYS makes me nervous...

[eccentricRN]

I work a general med/surg unit & our epidural pts are just included in with our regular pt load, as others have said it takes 2 to change the rate. Vitals are the same as anyone on a PCA, q4hrs. Occasionally I've seen cont. pulse ox, but not always. We change the bags ourselves.

[stalsrn]

I work on a surgical floor and we do get pts back post op with epidurals quite often. Our policy requires we do Resp, pulse ox, pain scale, CMS, and site assessment every 2 hours. 2 nurses have to verify original program and any changes, such as bag changes, bolus injections etc... Personally, I hate having epidurals, it seems every pt I have ever had has had some body part go numb!