Introduction
It is important for a nurse who takes care of a patient suffering from epidural infusion to understand the pathophysiology of pain. This is because a lot of caution and care should be administered when handling the patient. The nurse should understand the effects that the epidural analgesia has on the patient and complications it causes (McCaffery & Pasero, 1999).
The pathophysiology of pain
If the pain is caused by the activation of the nociceptive system which is a result of tissue injury, then the pain can be said to be nociceptive. Mr. Johnson has just had a left pneumonectomy which is a surgical procedure to remove a lung. This means that tissue damage or injury have occurred. Most of the time, Nociceptive pain is known to occur when the sensory system is activated normally by the noxious stimuli. This is usually a process that involves transduction, transmission, modulation and perception. Nociceptors are primary afferent neurons which are affected when tissue injury occurs. Nociceptors are usually found in the muscle joints, skin and in some cases the visceral tissues. They are small diameter afferent neurons which respond to stimuli (Calvino & Grilo, 2006).
These neurons consist of A-delta and C-fibers. The visceral fibers usually consist of specific receptors which are usually responsible for noxious chemical, mechanical or thermal stimuli. Noxious events are known to induce nociceptive processes. The noxious events might include somatic or visceral structures. The nociceptive process usually commence with the activation of these specific receptors. After activation, transduction occurs next (Farquhar-Smith, 2007).
Transduction is the process in which depolarization of the peripheral nerve is usually caused by the exposure to a sufficient stimulus. The depolarization of the primary afferent usually involves a process in which substances produced by tissues, the inflammatory cells and the neuron, influence transduction. Transmission of information along the axon to the spinal cord usually proceeds after the depolarization process. Modulation occurs further from processes initiated by glial cells (Ko & Zhou, 2004).
Complications manifested by pain in the post-operative patient
Neuropathic pain may imitate the quality of somatic pain. Some of the complications which are caused by pain include an uncomfortable feeling. This feeling is similar to that of burning, tingling or one which is caused by shock. Some of the syndromes caused by neuropathic may be associated with referred pain, allodynia, hyperalgesia or hyperpathiaa. These pains are caused by a specific type of stimulus. In addition, some of the complications are headaches and reduced blood pressure (Whitehead & Nussey, 2001).
Risk and benefits of epidural analgesia to manage pain
There are several benefits that epidural analgesia has in managing pain. One of the benefits of using epidural analgesia is that it reduces the possibility of occurrence of postoperative respiratory problems and chest infections. According to Block et al. (2003), Epidural analgesia, regardless of analgesic agent, location of catheter placement, and type and time of pain assessment, provide better postoperative analgesia compared to other methods used in managing pain.
In addition, epidural analgesia reduces the chances of a patient suffering from a heart attack (myocardial infarction). According to Beatie et al. (2001), patients who were treated using epidural analgesia in managing pain were in an unlikely position to suffer from a heart attack compared to the patients who used the other methods of anesthesia. Additionally, according to Wilson & Allman (2006), epidural analgesia is also known to reduce the requirements of blood transfusion. Furthermore, the rate at which the patient suffers from stress due to surgery is also reduced. When the sympathetic nervous system is blocked, the mobility of the intestines usually improves (Scott et al., 1995). This is another benefit of using epidural analgesia to manage pain.
While the use of epidural analgesia has its advantages, it is also associated with some effects. Some of the effects that are experienced include very large dosage of the epidural anesthetic. The intercostals muscles can be paralyzed together with the diaphragm. In addition to that, the heart losses its sympathetic function which in turn causes a profound drop in the blood pressure and the heart rate. This happens as a result of the epidural blocking the sympathetic nerves of the heart. Moreover, the phrenic nerves which supply the diaphragm are also blocked (Scott et al., 1995).
Priorities in nursing care
Taking care of a patient with epidural infusion, there are certain assessments that should be done. If any changes are detected in the condition of the patient, then proper interventions are usually carried out. (Sprigge & Harper, 2008).
Firstly, the nurses should engage themselves in checking the Pulse & Respiratory Rate. Additionally, Pain, Sedation & Nausea Scores, Motor Block Assessment and Dermatome Level Assessment should also be checked. On day one until day three, all the above observations should be recorded on the following time interval. Quarter hourly for half an hour, half hourly for one hour, one hourly for four hours should be the time intervals that should be used. Until day three, the remainder of infusion should be done two hourly. The frequency of the recordings can be extended to four hourly at night if all the above observations are acceptable at a certain range. Following the completion of the infusion, the epidural observations should be done for the next twenty four hours (Rosencher et al., 2007).
The oxygen saturation of the patient should occur continuously for two hours time interval. When the epidural is being administered, then the temperature should be done on a time interval of four hours and if the epidural has been removed, then it should be done after 24 hours. The epidural insertion site is another area that should be checked regularly, at least eight hourly. The epidural insertion site should be checked for position, inflammation leakage or any swelling. If the epidural has been removed, then the epidural insertion site should be checked after every two days. If the patient is discharged soon, then they should be given appropriate self care advice and guidance on what to do if they have any concerns (Williams & Wheatley, 2000).
The intravenous infusion should be checked and recorder on the epidural infusion and prescription chart. This is usually done on an eight hour. According to the waterlow score of the patient, the pressure area of the patient should be checked after two hours. If any pressure sores are detected, then certain measures should be taken to reduce the pressure sores. On the epidural infusion and prescription chart, the pressure area care box of the patient should be ticked (Shah, 2000). The recordings that should be done when reading the epidural infusion pump include the rate at which the infusion is occurring, the volume infused, and the volume which is remaining in the bag. The recordings should be done every two hours.
The epidural infusion pump program and the label of the drug against the prescription document should be done by the nurse at the beginning of the infusion. In addition, after every shift change, if the infusion is altered and if the bag is changed, the nurse should be able to verify the epidural infusion. Changing the epidural bags, the epidural infusion prescription together with the chart must be available. After the nurse has washed her hands, the nurse on duty should be in a position to operate the pump according to Smiths Medical (2004).
There are signs that the nurse should note in order to stop the epidural infusion. The patient should have a pain score of zero. For twenty-four hours, the patient should be in a position to tolerate the least 60ml of oral fluid. In additional, the commencement of regular oral analgesics such as Paracetamol, Tramadol and Dihydrocodeine should have already been started. Continuation of the regular pain assessment should occur. If the patient has been detected not to be in pain for about four hours, then the epidural can be removed. Considering the risk of infections, the epidural catheters have, they should be taken away after seven days (Rigg et al, 2002).
Decrease in blood pressure
If a patient who has an epidural infusion is suffering from a decrease in the blood pressure level, then the likely chance that have caused the blood pressure to drop might be the epidural local anesthetic blockade of the sympathetic nervous system. In addition, the vascular tone might have also reduced the resistance of the peripheral. Furthermore, a reduction in cardiac output might also have occurred (The Royal Free Hampstead NHS Trust, 1994).
Other possibilities that could caused the blood pressure to reduce might be the include hypovolaemia from post-surgical bleeding and fluid shift into the gut. If the skin is dry, this means that the patient is suffering from dehydration. In such a scenario, volume expanders should be administered, for instance the gelofusine. In addition to that, the nurse should also ensure that there is the availability of ephedrine. The nurse should also check if the patient is excreting dark colored urine. If the urine output of the patient has dropped to below 30mls/hr, then the epidural infusion rate of the patient should be reduced or stopped. Furthermore, the patient should be laid flat if he can tolerate it. The nurse should not tilt the head of the patient down but should raise the legs of the patient using pillows (The Royal College of Anaesthetists et al, 2004).
Headache
If the patient complains of a head ache, this can be a result of an accidental dural puncture during the insertion process of the catheter. This leads to a CSF loss from the site of the puncture. The headache can be very severe. If the patient complains of a headache, then the nurse on duty should define the cause of a headache. The nurse should also check if the patient has any previous history of headaches such as migraines (South Wales pain nurses forum, n.d).
The nurse should also ensure that the patient is put to bed rest oral hydration or analgesia. The nurse should also attempt darkening the room by drawing the curtains to ensure that minimal sunlight passes through the rooms. The nurse should also ensure that the patient does not involve him or herself in strenuous activities such as bowel movements or coughing. The nurse should also consider prescribing simple analgesia, such as paracetamol. The nurse should also consider the medication that the patient is being administered. Ninety percentage of the headaches that occur usually resolve spontaneously. In some cases, the patient might require a blood patch. The nurse should ask the anesthetic to perform this (American Society of Regional Anaesthesia, 2003).
Main complication of an epidural infusion
The main complication of an epidural infusion is unrelieved pain. If the patient is complaining of unrelieved pain, then the nurse should perform the following actions. Firstly, in accordance with the prescription, the nurse should increase the epidural rate. If the patient continues to complain of suffering from severe pain, the nurse should inspect the epidural site of insertion to make sure that the catheter has not fallen or moved.
This is usually done by referring to catheter mark at the skin level measurement on the front of the chart. In addition to that, the nurse should check the level of the dermatone to ascertain that the epidural is not one sided. If the nurses observe this, then they should turn the patient to make sure that he/she lies on one side. This is done so as to encourage gravitational spread. If the patient is complaining of the pain being on one area, then the patient should lie on the affected side. Moreover, the nurse should make sure that any additional analgesia is being taken by the patient (Coleman &Booker-Milburn, 1996).
Conclusion
If a nurse is to take care of a patient who has had epidural infusion, then the nurse should be able to understand the pathophisiology of pain. This will assist the nurse in taking good care of the patient. In addition, the nurse should be in a position to take care of the postoperative patient. The nurse should know the side effects that come with it plus what action to take if the patient complains of headache or pain. Furthermore, the nurse should also understand if anybody changes occur.
References
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