Postpartum nursing judgment

[mmm cdiff]

I've stumped myself with a question I made on my own! It's so NCLEXy though, I apologize.

Say you have a patient who is six hours postpartum, and she is complaining of a headache. She's had an epidural and has a history of gestational HTN. What would your first nursing action be?

a. administer Tylenol

b. check BP

c. check epidural site

I know it isn't A. I would guess that it would be B though, since blood pressure high enough to give you a headache is a major problem, and eclampsia is still a risk in the postpartum period... right? I just want feedback to reassure myself that a CSF leak from the epidural site wouldn't be the most critical thing.

...Or maybe I'm totally wrong. Opinions?

[CoffeeRTC, BSN, RN]

Would take 2 seconds to have her sit up or roll over to check the epidural site. Then check the bp. They can both be done together or within a few minutes.

[mmm cdiff]

In real life nursing practice, I'd agree with you 100%. But for NCLEX purposes, you'd go with C because it takes less time? Just trying to get clarification.

[angl987]

i would think the answer is b because htn is the most threatening to the patient. untreated hypertension can increase the risk of serious health problems such as heart attack and stroke.

[TonyaM73, ASN, RN]

I would think that it could be either B or C. It would depend on the wording. If either one had the word "Assess" instead of check, that would be the one that I would choose. NCLEX is all about assessments before action.

[Hushi05]

I would say B because 1) CSF leak headaches are positional and 2) a CSF leak does not mean it's leaking through the skin. That's a medical diagnosis that the anesthesiologist needs to make.

[JDougRN, BSN, RN]

9 years OB experience talking here- Check VS first, then the back. High BP can cause a stroke, CF leak isn't likely to be life threatening.

[klone, MSN, RN]

CHecking the epidural site is not going to tell you a lot. Every case of spinal headache I've had, I've never seen anything amiss with the epidural site. Definitely B.

[rn2kids]

Definately check the blood pressure!!!! Almost everyone that gets an epidural will get some type of headache following epidural and this is just due to the change in the pressure. If the mom has a headache due to high blood pressure and you waste time checking her epidural site, she could stroke out and die! Not only that, but think back to ABC's of nursing.....C=circulation (ie blood pressure) comes before E=epidural site!!!!

[mmm cdiff]

Thanks everyone!

[lrobinson5]

As someone who has experienced a CSF leak, the headaches are beyond painful, and at least for me there was no sign at the injection site. My case was easy because the anesthesiologist saw it happen as he was doing the procedure, so he was quick to respond when I needed a patch.

And above is very correct, laying flat you can't tell anything is wrong. When you sit upright is when the headache comes.

[rn/writer, RN]

As someone who has experienced a CSF leak, the headaches are beyond painful, and at least for me there was no sign at the injection site. My case was easy because the anesthesiologist saw it happen as he was doing the procedure, so he was quick to respond when I needed a patch.

And above is very correct, laying flat you can't tell anything is wrong. When you sit upright is when the headache comes.

So, have your patient lie flat while you take her BP.

Seriously, headaches serious enough to warrant a patch are comparatively rare where I work. Elevated blood pressures are more common.

An epidural headache will eventually resolve on its own even if no intervention is done. I'm not minimizing the importance of pain relief in the meantime, but the patient is not usually in a risky situation.

An elevated BP, however, is a different matter. You can have a mom who spikes after delivery. She may have been in the early stages of PIH an not have been diagnosed prior to delivery. Yes, the delivery will head off the worst problems, but PIH can take 1-2 days to resolve. This is also true for diagnosed PIH. Sometimes the need to start or continue mag is evident right away. But in other cases it isn't. At any rate, an epidural leak isn't life-threatening, but a drastically elevated or climbing BP certainly can be.

Vital signs are the way to go in this situation.