epidural nursing care plan 2009 - University Hospital of ...

1 Royal Manchester Childrens Hospital - Childrens Pain Management epidural nursing care plan (To be used in conjunction with the epidural protocol, epidural observation chart, continuous epidural infusion guidelines and EWS). Intravenous access must be maintained at all times for the entire duration of the epidural infusion NAME: PATIENT NUMBER: DOB: WARD CONSULTANT: REVIEW DATE. DATE SOLVED. DATE NUMBER NEED/PROBLEM INTENDED GOAL nursing INSTRUCTIONS. & SIG. & SIG. 1 epidural inserted Safety of child will 1. Observe, monitor and record specific epidural observations on epidural observation chart and infusion in be maintained, 2. epidural pump and bag to be checked against child's prescription sheet at start of each shift. progress problems identified 3. Child will be reviewed daily by on-call anaesthetist or member of children's pain team and action taken 4.

2 Consider pre-emptive urinary catheterisation in theatre in children receiving lumbar epidurals 2 Child will be Child's pain will be 1. Monitor and record observations on recovery chart every 5 minutes for 30 minutes and then observed in theatre well controlled. every 10 minutes if they remain within normal limits for the child. recovery Pain assessment 2. If additional analgesia bolus is required then child must remain in recovery for further 20. score will be 3 or minutes. less. Child will be 3. Record final set of epidural observations on epidural chart prior to discharge from recovery. haemodynamically 4. Check epidural prescription, rate, pump programme, epidural insertion site when handing stable over to ward/unit nurse. 3 Child will be To detect and treat 1. Observations to be recorded at least hourly on epidural chart.

3 Observed for any any potential 2. All children must have continuous oxygen saturation monitoring. complications complications 3. Infants under 6 months must have additional apnoea monitoring POTENTIAL PROBLEMS. 4 (a) Hypotension Maintain 1. Record blood pressure hourly and record blood pressure every 5 minutes for 20 minutes haemodynamic following any bolus dose of epidural analgesia status and maintain 2. Suspend infusion and inform on-call anaesthetist if systolic blood pressure falls below systolic blood minimum level set by anaesthetist. pressure above 3. Give fluid bolus of sodium chloride as prescribed. minimum level set 4. Resume epidural infusion when blood pressure within normal limits by anaesthetist. 5. Do not nurse child head down. 4 (b) Respiratory Child will maintain 1.

4 Ensure child has continuous oxygen saturation monitoring. If SP02 drops below level set by impairment or their respiratory anaesthetist or respiratory rate drops below minimum rate for child's age then suspend depression from function within infusion, give oxygen and contact on-call anaesthetist. Ensure Naloxone is available. either opiates or normal limits 2. Record child's sedation score hourly. If sedation score is 4 then suspend infusion, give high thoracic block oxygen and contact on-call anaesthetist. Consider removal of Clonidine from infusion if used. 3. With high thoracic epidural , if child complains of numbness or tingling in arms or hands then suspend infusion, sit child upright, give oxygen and contact on-call anaesthetist epidural nursing care plan D. Jonas/Aug 2009 Page 1 of 2.

5 4 (c) Loss of motor Child's skin will 1. Lower thoracic or lumbar epidural monitor movement in both legs hourly. If no movement in function or remain intact. Full both legs (motor score = 3) then suspend infusion and contact on-call anaesthetist. Loss of diminished movement of toes motor function may indicate severe neurological complication. sensation or feet, arms and 2. High thoracic epidural monitor movement in hands, arms and shoulders. If child complains hands will be of numbness or tingling in arms or hands then suspend infusion, sit child upright, give oxygen maintained and contact on-call anaesthetist. 3. Observe child's skin and pressure areas 3 hourly. Ensure 3 hourly movement or turning. 4 (d) Inadequate Child's pain will be 1. Assess child's pain hourly on scale of 0-10 using a pain assessment tool (Faces/numerical analgesia controlled ladder or FLACC scale.)

6 2. If pain score 7 or more contact on-call anaesthetist. 3. Give 6 hourly Paracetamol 4. Reposition child if pain apparent on only one side of body unilateral or patchy block. 5. Check epidural insertion site 3 hourly. 4 (e) Nausea & vomiting Child will have 1. Treat nausea and vomiting according to postoperative nausea and vomiting protocol. relief 4 (f) Urinary retention Child will maintain 1. Ensure optimum position for micturation. bladder function 2. Catheterise child if necessary. 4 (g) Itching (Pruritus) Child will have 1. Give intravenous Piriton (Chlorpheniramine) as prescribed according to BNFC. relief 2. Contact on-call anaesthetist if itching persists consider removal of Fentanyl from infusion 4 (h) Infection Infection will be 1. epidural bacterial filter will remain in place at all times secured to epidural catheter with prevented Tegaderm.

7 2. Bacterial filter position will be checked hourly. If disconnection occurs contact on-call anaesthetist and follow disconnection advice in continuous epidural infusion guidelines. 3. Check epidural catheter insertion site 3hourly, if red or inflamed contact on-call anaesthetist. 4. Record child's temperature at least 4 hourly. 4 (i) Loss of epidural Inadequate 1. Check epidural site 3 hourly for any leakage. Contact on-call anaesthetist if excessive catheter or leakage analgesia or leakage around site and child in pain. catheter loss will 2. Protect catheter by ensuring it is kept free from catching on bed sides etc. Take care when be prevented moving child around bed or out onto parent's knee or into a chair. 3. Ensure catheter is connected to filter and secured with Tegaderm.

8 5 Removal of epidural Child's epidural 1. The epidural catheter will be removed following ANTT principles. catheter catheter will be 2. Lie child on their side with spine curved or sit forward in bed or chair. removed safely and 3. Remove epidural dressing and tape humanely intact 4. Slowly pull out the epidural catheter, examine the tip to ensure the entire catheter has been removed. Document removal. Send catheter tip to pathology for culture and sensitivity. 5. If child receiving heparin follow advice regarding LMWH in continuous epidural infusion guidelines 6 Observe for further To ensure no 1. Continue to record all epidural observations for period of 6 hours post removal or cessation of complications further adverse the epidural infusion if Fentanyl has been administered in the infusion.

9 Complications Please do not hesitate to contact on-call anaesthetist or children's pain team if you have any concerns regarding a child with an epidural catheter in situ. epidural nursing care plan D. Jonas/Aug 2009 Page 2 of 2.