The care related to epidural analgesia is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, specific aspects of the care related to epidural analgesia, such as monitoring the infusion and assessment of patient response, may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

• Infusion device
• Epidural infusion tubing
• Prescribed epidural analgesic solutions
• Electronic medication administration record (eMAR) or medication administration record (MAR)
• Pain assessment tool and/or measurement scale
• Transparent dressing or gauze pads
• Labels for epidural infusion line
• Tape
• Emergency drugs and equipment, such as naloxone, oxygen, endotracheal intubation set, handheld resuscitation bag, per facility policy
• Gloves
• Additional PPE, as indicated
• Additional PCA equipment, based on prescribed administration; refer to Skill 10-4

Review the patient's health record and plan of care for specific instructions related to epidural analgesia therapy, including the prescribed intervention and conditions indicating the need for therapy. Check the health record for the prescribed drug; if epidural PCA, check the initial loading dose, dose for self-administration, and lockout interval. Review the patient's history for conditions that might contraindicate therapy, such as an allergic response to analgesics being used, coagulation disorders, anticoagulants, and localized infection or sepsis; relative contraindications include hypotension or compromised cardiovascular system, increased intracranial pressure, spinal abnormalities, and certain neurological conditions (Schrieber, 2015; Taylor et al., 2023). Check to ensure proper functioning of the infusion device. Assess the patient's understanding of epidural analgesia therapy and the rationale for its use.

Assess the patient's level of consciousness and vital signs. Assess the patient's level of discomfort and pain using an appropriate assessment tool and pain scale (refer to Fundamentals Review 10-1 through 10-4). Assess the characteristics of any pain and for other symptoms that often occur with the pain, such as headache or restlessness. Ask the patient what interventions have and have not been successful in the past to promote comfort and relieve pain.

Assess the patient's vital signs and respiratory status, including rate, depth, and rhythm, oxygen saturation level using pulse oximetry and level of carbon dioxide concentration using capnography. Assess the patient's sedation score (see Table 10-1 in Skill 10-4). Assess the patient's response to the intervention to evaluate effectiveness and for the presence of adverse effects. Assess for signs and symptoms of local anesthetic toxicity, including dizziness, drowsiness, tinnitus, circumoral numbness and numbness of the tongue, agitation, loss of consciousness, seizure, bradycardia/tachycardia, hypotension, cardiac arrhythmias (Galligan, 2020).

Implementation

Action	Rationale
1. Gather equipment. Check the medication prescribed against the original order in the health care record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's disorder and can also be used to educate the patient about the medication.
3. Prepare the medication syringe or other reservoir for administration, based on facility policy (see Chapter 5 for additional information).	Proper preparation and administration prevent errors.
4. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
5. Identify the patient.	Identifying the patient ensures that the right patient receives the intervention and helps prevent errors.
6. Show the patient the device, and explain the function of the device and the reason for its use. Explain the purpose and action of the medication to the patient.	Explanation encourages patient understanding and engagement and reduces apprehension.
7. Close the door to the room or pull the bedside curtain. Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods (The Joint Commission, 2021). Refer to Chapter 5 for additional information related to medication administration.	Closing the door or curtain provides for patient privacy. Identifying the patient ensures the right patient receives the medications and helps prevent errors. The patient's room number or physical location is not used as an identifier (The Joint Commission, 2021). Replace the identification band if it is missing or inaccurate in any way.
8. Complete necessary assessments before administering the medication. Check allergy bracelet or ask the patient about allergies. Assess the patient's pain using an appropriate assessment tool and measurement scale (see Fundamentals Review 10-1 through 10-4).	Assessment is a prerequisite to administration of medications. Accurate assessment is necessary to guide treatment and relief interventions and to evaluate the effectiveness of pain control measures.
9. Have an ampule of 0.4-mg naloxone and a syringe at the bedside, according to facility policy.	Naloxone reverses the respiratory depressant effect of opioids.
10. Check the label on the prefilled drug syringe or reservoir with the medication record and patient identification, verifying the drug, concentration, dose, and rate of infusion. Obtain verification of information from a second clinician, according to facility policy. Scan the bar code on the package, if required.	This action verifies that the correct drug and dosage will be administered to the correct patient. An independent double check by two clinicians is recommended prior to initiation of the PCA and when the syringe, solution container, drug, or rate is changed (Gorski et al., 2021). Confirmation of information by a second clinician helps prevent errors.
11. Scan the patient's barcode on the identification band, if required (The Joint Commission, 2021). Based on facility policy, the third check of the medication label may occur at this point. If so, read the label and recheck the label with the eMAR/MAR before administering the medications to the patient.	Scanning of the patient's barcode on identification band provides an additional check to ensure that the medication is given to the right patient. Many facilities require the third check to occur at the bedside, after identifying the patient and before administration. If facility policy directs the third check at this time, this third check ensures accuracy and helps prevent errors.
12. After the catheter has been inserted and the infusion initiated by the anesthesiologist or radiologist, verify the drug, concentration, dose, and rate of infusion; if epidural PCA is in use, verify the dose interval, and lockout interval. Obtain verification of information from a second clinician, according to facility policy.	These actions ensure that the appropriate drug dosage will be administered. An independent double check by two clinicians is recommended prior to initiation of the PCA and when the syringe, solution container, drug, or rate is changed (Gorski et al., 2021). Confirmation of information by a second clinician helps prevent errors.
13. Tape all connection sites. Label the bag, tubing, and pump apparatus “For Epidural Infusion Only.” Do not administer any other opioid or adjuvant drugs without the approval of the clinician responsible for the prescribed epidural analgesia.	Taping prevents accidental dislodgement. Labeling prevents inadvertent administration of other IV medications through this setup (Morton & Fontaine, 2018). Additional opioid or adjuvant medication may potentiate the action of the epidural analgesic, increasing the risk for respiratory depression (Kyle & Carman, 2021).
14. Put on gloves. Assess the catheter exit site and apply a transparent dressing over the catheter insertion site, if not already in place (Figure 2). Secure the catheter and tubing, based on facility policy. Remove gloves and additional PPE, if used. Perform hand hygiene.	The transparent dressing protects the site while still allowing assessment. Securing of catheter and tubing prevents accidental displacement and removal. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene reduces transmission of microorganisms.
15. Refer to Skill 10-4 for additional considerations if the epidural analgesia is being administered as PCA.	Patient-controlled analgesia (PCA) requires additional patient education and nursing intervention to provide safe nursing care and promote optimal patient outcomes. Refer to Skill 10-4.
16. Initiate continuous capnography and/or pulse oximetry, based on facility policy.	Continuous capnography and/or pulse oximetry has been suggested for use in all patients receiving PCA opioids for early detection of opioid-induced respiratory depression; continuous capnography should be used in all patients receiving supplemental oxygen (Fazio & Firestone, 2020; Khanna et al., 2020).
17. Monitor the infusion rate according to facility policy. Assess the patient's response to the medication: Assess the patient's pain at least every 4 hours or more often, as needed, based on patient's individual risk factors. Monitor vital signs, especially respiratory status, including respiratory rate, depth, and quality and oxygen saturation every 2 to 4 hours or more often, as needed, based on patient's individual risk factors and situation. 18. Assess the patient's response to the medication: Assess the patient's sedation score (see Table 10-1 in Skill 10-4) and end-tidal carbon dioxide level (capnography) at least every 4 hours or more often, as needed, based on patient's individual risk factors.	Monitoring the infusion rate prevents incorrect administration of the medication. The plan of care and monitoring strategies should be driven by reassessment according to level of risk (Jungquist et al., 2020). Continued assessment at frequent intervals helps evaluate the effectiveness of the drug and reduce the risk for complications (Fazio & Firestone, 2020; Gorski et al., 2021; Jungquist et al., 2017a, 2017b). The plan of care and monitoring strategies should be driven by reassessment according to level of risk (Jungquist et al., 2020). Sedation occurs before clinically significant respiratory depression (Hall & Stanley, 2019). Respiratory depression can occur with the use of opioid analgesics (Fazio & Firestone, 2020; Hall & Stanley, 2019). Capnography provides an earlier warning of respiratory depression as compared to continuous oximetry (Casey, 2015; Gorski et al., 2021; Jungquist et al., 2017a, 2017b). Opioids can depress the respiratory center in the medulla. A change in the level of consciousness is usually the first sign of altered respiratory function.
19. Keep the head of bed elevated 30 degrees unless contraindicated.	Elevation of the patient's head minimizes upward migration of the opioid in the spinal cord, thus decreasing the risk for respiratory depression.
20. Monitor the patient's blood pressure and pulse.	Hypotension can result from the use of epidural analgesia (NHS, Hull University Teaching Hospitals, 2018).
21. Monitor urinary output and assess for bladder distention.	Epidural analgesia can cause urinary retention (NHS, Hull University Teaching Hospitals, 2018).
22. Assess motor strength and sensation every 4 hours or as specified by facility policy.	The catheter may migrate into the intrathecal space and allow opioids to block the transmission of nerve impulses completely through the spinal cord to the brain.
23. Monitor for adverse effects (pruritus, nausea, decreased gastric motility, headache, constipation, and vomiting) (Gai et al., 2020; Galligan, 2020; Kyle & Carman, 2021; UHN, 2017). Monitor for signs and symptoms of local anesthetic toxicity, including dizziness, drowsiness, tinnitus, circumoral numbness and numbness of the tongue, agitation, loss of consciousness, seizure, bradycardia/tachycardia, hypotension, cardiac arrhythmias (Galligan, 2020).	Opioids may spread into the trigeminal nerve, causing itching, or resulting in nausea and vomiting owing to slowed gastrointestinal function or stimulation of a chemoreceptor trigger zone in the brain (Galligan, 2020). Medications are available to treat these adverse effects. Neonates; infants; older adults; and patients with chronic renal, cardiac, or liver disease are at increased risk of local anesthetic toxicity (El-Boghdadly et al., 2018).
24. Assess for signs of infection, hematoma, or abscess at the insertion site.	Inflammation or local infection or hematoma can develop at the catheter insertion site (Taylor et al., 2023).
25. Assess the catheter-site dressing for drainage, based on facility policy. Notify the anesthesia provider or pain management team immediately of any abnormalities. Change the dressing over the catheter exit site per facility policy using aseptic technique. Change the infusion tubing as specified by facility policy.	The catheter-site dressing should remain clean, dry, and intact. Abnormalities in the dressing may indicate leakage of cerebrospinal fluid or catheter dislodgement. Dressing and tubing changes using aseptic technique reduce the risk for infection.
26. If using epidural PCA, make sure the patient control (dosing button) is within the patient's reach.	Easy access to the control is essential for the patients to use the device.
27. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.