Transcript Self-Learning Module Added Nursing Competency Patient

Originally developed by Susan Warman, BN., Helen Gourlay,BN/MN. ,and Janet Walker, BN.
January 1997
Revised Dec 2005 by Nancy Schuttenbeld -Acute Pain Nurse for RVH, Reviewed by Dr. Rick
Chisholm, Anesthesiology, Marie Chase- Learning Services.
POLICY


Registered Nurses (RN’s) are required to be certified in the
monitoring and Care of the Patient receiving Neuraxial
Analgesia.
STANDARDS




The RN will:
Complete the Self – Learning Module on Monitoring and Care
of the Patient receiving Neuraxial Analgesia.
Attend the in service on Neuraxial Analgesia and complete a
written exam with a passing mark of 85%.
Demonstrate application of knowledge in the care of the
patient receiving neuraxial analgesia.




Patients have a right to the best pain relief possible.
The Acute Pain Service (APS) at River Valley Health
(RVH) involves a team of anesthesiologists and an
acute pain service nurse who implement and maintain
acute pain management for surgical and non-surgical
patients.
Neuraxial analgesia (subarachnoid bolus or epidural
opioid / local anesthetic) is used in the management of
acute post- operative and post- traumatic pain. Post–
intraspinal opioids serve as an effective way to manage
and control acute pain by providing:
A controlled method of pain relief.
2. Safe delivery of intraspinal medications to patients.

Post – Intraspinal Opioids


Category: Added Nursing Competency



Policy:
The patient will be cared for on a nursing unit that can meet the total needs of the patient most appropriately ie. medical
status, hemodynamic monitoring and nursing care requirements.


Patients receiving intraspinal opioids will be cared for by RN’s certified in the added nursing competency on the general
med/surg units, PACU, obstetrical service and ICU.


Patients receiving epidural analgesia with anaesthesia (ie. Marcaine) whether intermittently or by continuous infusion
will be cared for by certified RNs in ICU, PACU or Labor and Delivery.


Administration of bolus medication via the epidural catheter is a medical responsibility. RN’s may prepare, hang and
initiate medication for continuous epidural infusion. (See Nursing Policy & Procedure re: Perth Hospital).


Removal of the epidural catheter is a medical responsibility but may be removed by the acute pain nurse at the DECRH
and RN’s in Perth who are certified for this function (with a physician’s order).


Pain management of the patient while receiving intraspinal analgesia is the responsibility of the Acute Pain Service (APS)
of the Department of Anesthesia in collaboration with the attending physician, RN’s and other appropriate health team
members. The patient will be assessed daily by an anesthesiologist.


An anesthesiologist is responsible for ensuring that repeat bolus doses are administered. (See updated nursing policy &
procedure re: Perth hospital).


A pain flow sheet will be used for patients on the APS at the DECRH.

Standards


In collaboration with other appropriate health team members: the anesthesiologist will determine if the patient is a
suitable candidate for intraspinal opioids.


The Department of Anesthesia at the DECRH will keep a registry in the OR for patients receiving intraspinal opioids
including patient unit, date and time of initial administration, frequency and time of top-ups and date of removal of
epidural catheter.


Patient transfers to an alternate unit will be reported to the Department of Anesthesia immediately.


Certified RN’s caring for the patient will follow the established protocol for patients monitoring and guidelines for
response to complications or emergency situations.


Emergency equipment must be immediately available and functioning. This includes O2 and suction, pulse oximetry,
ambu bag and mask, and Naloxone.


Documentation will reflect date, time, medication, dosage, route of administration and patient response.





Data Source
Neuraxial Analgesia/ Post- Intraspinal Opioid Physician Orders 06.6000-64-(05/06)D
Anesthesia Record (7500-39)
Patient Notes




Original date: March 1993
Revised: January 1997, April 2003, August 2005

Learning Objectives


Following completion of the self-learning module, the RN will:









Understand the physiology of pain transmission
Understand the anatomy of the subarachnoid and epidural space and the
actions of local anesthetics at this level
State the indication for epidural opioid analgesia and subarachnoid opioid
analgesia.
Identify the common opioids used for epidural analgesia.
Identify potential complications of neuraxial analgesia and state actions to
be taken if side effects / complications occur.
Identify the nursing care for a patient receiving medications via bolus and
continuous epidural infusion or subarachnoid bolus.
Identify indications for the use, dosage and implications for Naloxone.
Complete the test and Performance Criteria checklist of skills for care and
monitoring of a patient receiving neuraxial analgesia.

POST - INTRASPINAL OPIOID PROTOCOL




1. In ICU, PACU and L&D
–monitor vital signs as per unit routine
–discharge as per unit discharge criteria








On General Units
-After initial bolus, monitor V/S as per post operative routine and respiratory rate
and sedation score q 2 hours X 24 hours than q 4 hrs or more frequently if patient
condition warrants.
-For continuous infusion, monitor vital signs q 4 hours.
-Following administration of subsequent bolus doses, respiratory rate and sedation
score q 1 h X 12 hrs.



Inspect catheter site every shift and document. Notify acute pain nurse or anesthesiologist
if catheter insertion site shows signs of leakage, infection or bleeding. Reinforce site.








If respiratory rate <8/min and/or sedation score is ≥3, implement the following:
Rouse patient and encourage to breathe
Start pulse oximetry and check pulse and BP
Administer O2 by mask at 5L/min
Notify Acute Pain Service or anesthesiologist on call
If unresponsive, Rx Naloxone 0.1mg IV, repeat q 3 min prn until patient
responsive and respiratory rate 8 or greater.


No supplemental opioids or sedatives unless approved by the anesthesiologist.


Notify anesthesiologist before patient is started on Warfarin, LMWH, or a Heparin infusion.


7. Maintain IV access for 12 hours after last intraspinal bolus or discontinuing infusion.


8. Assess motor function regularly.



9. Activity and diet in accordance with attending physician’s orders.
10. Side effects:




Nausea /vomiting- Rx as ordered by anesthesiologist
Pruritus- Rx as ordered by anesthesiologist
Urinary retention- catheterize once in/out: if repeat needed- use foley
catheter. Ortho patients follow ortho standing orders




11. For breakthrough pain (score 4 or more) – Rx as ordered by anesthesiologist.
Report off unit transfers to the Anesthesia Department so that the registry can be
kept current.


Sedation Score
S -Normal sleep – easily roused


0 -Alert - awake


1 - Drowsy – occasionally drowsy, easily
roused


2 - Drowsy – repeatedly drowsy, easily
roused


3 -Very drowsy – difficult to rouse


4 -Unresponsive

•In RVH, use the 0 – 10 numeric
rating scale for pain intensity
assessment whenever possible. In
cases where an alternate scale is
used, it is imperative that the
patient’s record indicate which
scale is being used.
*Pain Score
0 -No pain
2 -Mild pain – moves easily
4 -Discomforting – moves with
difficulty
6 -Distressing – unable to move
8 -Horrible
10 -Worst imaginable (excruciating)

Theory


Neuraxial is defined as pertaining to the cerebrospinal axis. Epidural opioid /local anesthetic administration and
subarachnoid opioid administration are two alternative postoperative pain control techniques. Together they are
referred to as neuraxial opioid analgesia.



The spinal cord is covered by three meninges (membranes).
Diagram: Spinal Anatomy –as appears in McCaffery M., Pasero,C.Pain: Clinical Manual (2nd Ed.) 1999. Mosby, Inc.,
p.216.



Pia Mater –Innermost layer that adheres to the surface of the spinal cord and brain. It contains many blood vessels to
supply the spinal cord.
Arachnoid Mater – Middle transparent layer. It is separated from the pia mater by the CSF filled subarachnoid space.


Dura Mater – The strong, tough outer layer that consists of dense, fibrous connective tissue.


Epidural Space – The potential space that lies between the dura mater and the vertebral canal and extends from the
cranium to the sacrum. This space contains blood vessels, fat and connective tissue.


Subarachnoid Space – is located between the arachnoid and the pia mater. This area contains cerebrospinal fluid (CSF).
It is also called the spinal or intrathecal space. In general, it only requires 1/10 of the dose of medication used in the
epidural space.

“Spinals” or Subarachnoid Opioid Analgesia


Subarachnoid opioid analgesia is also referred to as “intrathecal”
or “spinal”. Intrathecal is defined as within the spinal canal. With
subarachnoid analgesia, the opioid is administered directly into
the subarachnoid (intrathecal) space. This space is inside the
dura/arachnoid and contains the cerebral spinal fluid (CSF). The
intrathecal space, containing the CSF that bathes the spinal cord,
runs parallel to the epidural space. The dura and arachnoid mater
separate the intrathecal and epidural spaces. Subarachnoid opioid
analgesia is usually a single administration into the subarachnoid
space. Doses for subarachnoid analgesia are much smaller doses
than epidural doses, often 1/10 the dose. The risk of infection is a
potential complication and therefore catheters are rarely left in
place. A subarachnoid bolus may provide analgesia for 6 – 24
hours.


Epidural local anesthetics and local anesthetic/opioid admixtures
Local anesthetics administered via the epidural route, block pain signals in the dorsal
nerve root before they enter the spinal cord. Sympathetic impulses are also affected
resulting in vasodilatation and potentially hypotension. Local anesthetics can
potentially block motor nerves as well, resulting in motor weakness.




The body can be mapped according to the sensory and motor innervation derived from
the spinal nerve roots. An area whose sensation is supplied by a particular spinal nerve
root is called a dermatome. The motor function supplied by a spinal nerve root is called
a myotome. Epidural local anaesthetics can result in segmental blocks involving several
dermatomes and if potent enough, myotomes as well. Lumbar epidural local
anesthetics, because they involve lumbar segments, may cause extremity weakness in
addition to sensory loss if the block is dense enough. By using a low concentration of
local anaesthetic, sensory pathways may be blocked leaving motor pathways
relatively intact. The goal is to provide analgesia WITHOUT motor block to ensure
patient safety. Any patient receiving local anaesthetic in the epidural infusion must
be cared for in the ICU, PACU or L&D. Motor function and sensory level assessments
are completed as per unit routine.
It is imperative to mention that if a patient develops sensory or motor loss following the
initiation of an epidural opioid infusion where NO local anaesthetic is used, immediate
medical attention is required. See epidural hematoma section, page 11). Notify the
APS/anesthesiologist on call stat.

Epidural Analgesia


Epidural analgesia refers to insertion or placing a catheter between the dura mater and the vertebral
arch. This potential space contains fat, blood vessels and nerves. The opioids diffuse across the dura
and subarachnoid space and bind with the receptors in the substantia gelatinosa in the spinal cord.
Because the opioid does not cross the blood brain barrier, pain relief results from drug levels in the
spinal cord rather than in the plasma, with little central or systemic distribution of the drug. Pain is
relieved with smaller doses and therefore less severe side effects, since the drug crosses slowly
through the dura mater and is absorbed directly into the CSF and spinal cord and eventually to the
opiate receptors in the dorsal horn.


Opioids for Epidural Analgesia


Morphine is a water – soluble (hydrophilic) opioid frequently used for epidural injection. The
epidural version of morphine is preservative free. Absence of preservative is vital to avoid irritation
or damage to neural structures. Morphine is one of the least lipid soluble of the opiate analgesics and
therefore has a slow rate of uptake in the spinal cord and tends to linger longer in the CSF. This
means a delayed onset of approximately 30 –60 minutes and prolonged duration of action 12-24
hours.



Fentanyl has a high lipid solubility, which allows it to reach the CSF quite quickly which leads to
rapid onset of narcotic effect.
Dilaudid is often used for continuous infusion because of its greater concentration.

Epidural Infusions:















DRUG
ONSET
DURATION
Morphine
30-60 minutes
*Up to 24 hrs
Fentanyl
10-15 minutes
*4-5 hrs
Dilaudid
10-20 minutes
*6-17 hrs