Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

229

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 10-5

Caring for a Patient Receiving

Epidural Analgesia (Continued)

Comments

12. Assess the catheter exit site and apply a transparent dress-
    ing over the catheter insertion site, if not already in place.
    Remove gloves and additional PPE, if used. Perform hand
    hygiene.


13. Monitor the infusion rate according to facility policy.
    Assess and record sedation level and respiratory status
    every hour for the first 24 hours, then at 4-hour intervals
    (or according to agency policy). Notify the physician if the
    sedation rating is 3 or 4, the respiratory depth decreases,
    or the respiratory rate falls below 10 breaths per minute.


14. Keep the head of bed elevated 30 degrees unless
    contraindicated.


15. Assess the patient’s level of pain and the effectiveness of
    pain relief.


16. Monitor urinary output and assess for bladder distention.


17. Assess motor strength and sensation every 4 hours.


18. Monitor for adverse effects (pruritus, nausea, and vomiting).


19. Assess for signs of infection at the insertion site.


20. Change the dressing over the catheter exit site every 24 to
    48 hours or as needed per agency policy using aseptic tech-
    nique. Change the infusion tubing every 48 hours or as
    specified by agency policy.

ExcellentSatisfactoryNeeds Practice