Initial nursing care for any medical complication is usually to check for any disease symptoms. The priority of nursing care would be to conduct a vital sign observation and a neuro-observation. A nurse would be checking for the effectiveness of treatment offered to Mr. Johnson and any side effects that he would be expressing. Vital signs include the normalcy of breathing, responses to sensory stimulus, and alertness of the patient. A positive response indicates that the patient is conscious and capable of undergoing additional tests. Failure to respond positively to sensory stimulants or the presence of struggles to breathe or move indicates complications that need further attention (Tixier, et al., 2010). Nurses have to document all their observations to assist in subsequent diagnosis and treatment.
The nurse has to maintain the fluid balance chart. Dressings should remain in situ. However, any presence of excessive leakage at the site would necessitate a change of the dressing or its modification. The balance chart for fluids indicates any mismatch of the epidural infusion that infections would cause. Sometimes the fluids given to the patient might be more than the actual patient losses. The documentation of the fluid balance assists in ensuring that excess replacement does not happen. The fluids balance chart would also indicate an abnormality in the rate of flow in the infusion line.
The third priority for the nurse would be to check for any nausea and vomiting. This check should be done hourly for the first twelve hours, and scores recorded on the general observation chart. Nausea and vomiting are indications of a complication caused by the epidural infusion procedure. They are symptoms of a dural puncture or any other side effect that causes a malfunction in the autonomic nervous system’s functions (Baysinger et al., 2011). Vomiting and nausea are also indications that the patient is having hypotension. This would be caused by cardiac arrhythmias, hypervolemia, or a too rapid infusion.
Fourth, the nurse will look for any signs of analgesia toxicity. This is a complication resulting from intrapleural analgesia. The nurse checks the records at the beginning of his or her shift and will then document any medical record thereafter. To determine the presence of toxicity, the nurse would check the insertion site for any redness swelling, or pain. The mark on the patient’s skin has to match the insertion details as documented. The dressing should be intact, and any abnormality would indicate potential aesthetic toxicity. Toxicity would arise from an effective dispersion of the infuscate at the insertion point. The hourly doses in the first eight hours may also result in toxicity. Early detection of toxicity allows physicians to change the epidural infusion regime or stop it in favor of another method of analgesia.
The nurse has to check the pain levels and sedation score of the patient as the fifth nursing care priority. Epidural drugs help the patient to experience less pain. However, the patient may still experience breakthrough pain despite the epidural infusion. The hourly rate of continuous infusion may lead to poor dispersion of the infuscate in the patient, leading to persistent pain. The nurse has to compare current pain levels with the documented pain levels.
If there is no change, or there is an increase in the pain levels, then the patient would need supplementary analgesia (Lim et al., 2010). Meanwhile, the sedation score indicates how low the patient’s irritation and agitation have reduced because of the epidural infusion. Any subsequent medical operation on the patient has to happen when the patient is fully sedated. Sedation scores offer a benchmark for evaluating the effectiveness of the nerve transmission blockade to the brain and spine (Bird & Wallis, 2002). Sedation scores are important in reviewing patient injury that may arise due to the method used. In case of any ascending block or motor block, the dermatome level check will identify it.
The sixth care for the nurse would be to check the patient’s dermatome level. This routine assists in determining the depth of the sensory block and ensuring that there is a proper cover of the surgical site (Mulcahey, Gaughan, & Betz, 2009). There should be a sterile, transparent, semi-occlusive dressing over the site (Murdoch, 2005). Dermatome levels relate to the existence of a spine or viral infection. Thus, the nurse should look for indications of pain or rash in the dermatomes to check for any unwanted effects of local anesthetic solution.
The presence of sensory blocks informs the nurse that the patient requires additional care against physical injury. When the patient has an immobile limb, nurses have to protect it from any danger since the patient has lost the ability to do it. Nurses are required to use ice when determining the extent of the sensory block. The patient has to assist the nurse in locating the areas in his body where he is experiencing more acute pains than the rest of the body (N & T, 2010). If the nurse determines that the sensory block extends beyond the nipple level of the patient, he or she has to inform the hospital’s anesthetist (Murdoch, 2005).
The seventh care priority would be epidural catheter care. Nurses have to check the epidural insertion site often and thoroughly. They would be checking for inflammation, exudation, and movement of the catheter as vital signs that require urgent medical attention. An improper movement of the catheter would lead to a high-block For example if the catheter moves to the subarachnoid space, then, even small doses of the local anesthetic lead to a high-block, which is undesirable. A displacement of the catheter would lead to inadequate analgesia for the patient.
References
Anderson, E., & McFarlane, J. (2012). Community as partner: Theory & practice in nursing. Philadelphia: Lippincott Williams Wilkins.
Apok, V., Gurusinghe, N. T., Mitchell, J. D., & Emsley, H. C. (2011). Dermatomes and dogma. Practical Neurology, 11(2), 100-105.
B, B., M, D., H, K., S, J. T., & L, N. (2011). Mechanosensitivity before and after hysterectomy: a prospective study on the prediction of acute and chronic postoperative pain. British Journal Of Anaesthesia, 107(6), 940-947.
Baker, G., & Norton, P. (2004). The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada. CMAJ, 170(11), 34-41.
Baysinger, C. L., Pope, J. E., Lockhart, E. M., & Mercaldo, N. D. (2011). The management of accidental dural puncture and postdural puncture headache: a North American survey. Journal Of Clinical Anesthesia, 23(5), 349-360.
Bird, A., & Wallis, M. (2002). Nursing knowledge and assessment skills in the management of patients receiving analgesia via epidural infusion. Journal of Advanced Nursing, 40(5), 522-531.
Bösenberg, A. T., Thomas, J., Cronje, L., Lopez, T., Crean, P. M., Gustafsson, U., et al. (2005). Pharmacokinetics and efficacy of ropivacaine for continuous epidural infusion in neonates and infants. Pediatric Anesthesia, 15(9), 739-749.
Burch, M…, McAllister, R. K., & Meyer, T. A. (2011). Treatment of local-anesthetic toxicity with lipid emulsion therapy. American Journal of Health-System Pharmacy, 68(2), 125-129.
Bush, N. J., & Griffin-Sobel, J. P. (2003). Acute postoperative pain management and malfunctioning epidural catheter. Clinical challenges, 30(2), 217-218.
Carrel, D. (2011). My dream to trample AIDS: What everyone at any age should know about HIV/AIDS. Indianapolis: Dog Ear Publishers.
Cichoki, M. (2009). Living with HIV: A Patient’s Guide. New York: McFarland.
Darvish, B., Gupta, A., Alahuhta, S., Dahl, V., Helbo-Hansen, S., Thorsteinsson, A., et al. (2011). Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey. Acta Anaesthesiologica Scandinavica, 55(1), 46-53.
Forero, M., Neira, V. M., Heikkila, A. J., & Paul, J. E. (2011). Continuous lumbar transversus abdominis plane block may spread to supraumbilical dermatomes. Canadian Journal Of Anaesthesia, 58(10), 948-951.
Jackson, S.-R., Williams, G. N., Lee, J., Baer, J. F., Warburton, D., & Driscoll, B. (2011). A Modified Technique for Partial Pneumonectomy in the Mouse. Journal of Investigative Surgery, 24(2), 81-86.
Kim, M., & Yoon, H. (2011). Comparison of post-dural puncture headache and low back pain between 23 and 25 gauge Quincke spinal needles in patients over 60 years: randomized, double-blind controlled trial. International Journal Of Nursing Studies, 48(11), 1315-1322.
Lim, Y., Chakravarty, S., Ocampo, C. E., & Sia, A. T. (2010). Comparison of automated intermittent low volume bolus with continuous infusion for labour epidural analgesia. Anaesthesia & Intensive Care, 38(5), 894-899.
Meyers, S. (2004). Balanced scorecards help the board make the patient safety their no. 1 priority. Trustee, 2(4), 1-4.
Mulcahey, M. J., Gaughan, J., & Betz, R. R. (2009). Agreement of repeated motor and sensory scores at individual myotomes and dermatomes in young persons with complete spinal cord injury. Spinal Cord, 47(1), 56-61.
Murdoch, J. (2005). Ensuring prompt diagnosis and treatment of epidural abscess. Nursing Times, 101(20), 36.
N, S. E., & T, K. A. (2010). The extent of temperature sense and pain appreciation recovery in the dermatomes of cauda equine roots after lumbar intervertebral dischernia elimination. Fiziologiia Cheloveka, 36(3), 95-101.
Okutomi, T., Saito, M., Mochizuki, J., & Kuczkowsk, i. K. (2009). Combined spinal-epidural analgesia for labor pain: Best timing of epidural infusion following spinal dose. Archives Of Gynecology And Obstetrics, 279(3), 329-334.
Parker, R. K., Connelly, N. R., Lucas, T., Serban, S., Pristas, R., Berman, E., et al. (2007). Epidural clonidine added to a bupivacaine infusion increases analgesic duration in labor without adverse maternal or fetal effects. Journal of Anesthesia, 21(2), 142-147.
Ruan, X., Tadia, R., Liu, H., Couch, J. P., & Lee, J. K. (2008). Edema caused by continuous epidural hydromorphone infusion: a case report and review of the literature. Journal Of Opioid Management, 4(4), 255-259.
Shipton, E. A. (2011). The transition from acute to chronic post surgical pain. Anaesthesia And Intensive Care, 39(5), 824-836.
Tixier, S., Bonnin, M., Bolandard, F., Vernis, L., Lavergne, B., E, B. J., et al. (2010). Continous patient-controlled epidural infusion of levobupicacaine plus sufentanil in labouring primiparous women: effects of concentration. Anaesthesia, 65, 673-680.
TĂĽre, H., Eti, Z., G, F. Y., DĂĽzgĂĽn, O., Mutlu, Z., & KarabaÄźli, P. (2010). Histopathological effects on epidural tissue of bolus or continuous infusions through an epidural catheter in ewes. Anaesthesia, 65(5), 473-477.
Vallejo, M. C., Ramesh, V., Phelps, A. L., & Sah, N. (2007). Epidural labor analgesia: continuous infusion versus patient-controlled epidural analgesia with background infusion versus without a background infusion. The Journal of Pain, 8(12), 970-975.
Varela, H., & Burns, S. M. (2010). Use of lipid emulsions for treatment of local anesthetic toxicity: A case report. AANA Journal, 78(5), 359-364.
Vaughn, T. (2006). Engagement of Leadership in Quality Improvement Initiatives: Executive quality improvement survey results. Journal of Patient Safety, 2(2), 4-16.
White, L. (2001). Effective governance through complexity thinking and managment science. System Research and Behavioral Science, 18(1), 23-44.
Zablocki, E. (2007). IHI calls on boards to lead on quality and safety: An interview with Jim Conway. Great Boards, 7(2), 1-3.