Pain Management Class Post-Test

Transcription

1 Name: Date: Unit: Pain Management Class Post-Test 1. Contraindications to regional anesthesia include (circle all that apply): a. Allergy to medication b. Clotting disorders or anticoagulation therapy with elevated PT/PTT/INR, and/or thrombocytopenia c. Spinal abnormalities that prevent catheter insertion d. Active infection without identified source e. Increased intracranial pressure 2. The following is true regarding ambulating a patient with an epidural, interpleural, intrathecal, and nerve block (circle all that apply): a. Check orthostatic blood pressure before ambulation. If SBP <90 mm Hg, and/or patient complains of dizziness, do not ambulate b. Do not ambulate patient with a Bromage Motor Scale <2 c. Licensed staff (PT or RN) must be present to assist in the initial ambulation (2 staff members) d. Ambulate the patient as per order of the Primary Service unless do not ambulate is ordered on the epidural, interpleural, and nerve block infusion orders form e. Do not ambulate any patient with an epidural, interpleural, intrathecal, and nerve block 3. True False Do not use alcohol to cleanse the insertion site because alcohol is neurotoxic. 4. Side effects of epidural, interpleural, intrathecal, or nerve block therapy may include all of the following except: a. Nausea b. Vomiting c. Itching d. Urinary retention e. Numbness f. Respiratory depression g. Urinary tract infection h. Constipation i. Twitching j. Confusion k. Hypotension l. Sedation

2 5. Notify Anesthesia Provide Staff (APS) and stop the infusion if necessary for all of the following except: a. Systolic Blood Pressure <90 mm Hg b. Respiratory rate <10 c. Heart Rate <80 d. Pain Scale >5 and c/o inadequate analgesia e. Sedation Scale (LOS) >4 f. Motor Scale >2 g. Seizure, confusion, complaints of metallic taste, tinnitus h. Side effects unrelieved with ordered medications i. Drip not infusing; disconnected, accidentally removed, leaking epidural catheter, redness, induration, drainage or pain at insertion site. 6. True False When a patient is receiving pain medications via Regional Anesthesia Catheter (R.A.C.) they should not be given sedatives, narcotics, anticoagulants (i.e. Lovenox, Heparin, Coumadin), antiplatlet medications (i.e.., Plavix, Pletal, Ticlid, etc.) aspirin, or additional antiemetics unless approved by Anesthesia Pain Service. 7. Match the tubing: a. Yellow tubing PCA b. Clear tubing Epidural Case Studies Your patient has an epidural in place regulated by a CADD pump. He has had a Total Knee replacement and you are just receiving him from PACU. He is complaining of a severe headache in the occipital region with a pain rating of 10. His vital signs are: B/P 160/90, heart rate 195, regular respirations of 19. His knee pain is rated at a What is your assessment? a. Patient has a subdural bleed b. The Dura was inadvertently punctured during epidural catheter insertion c. The epidural catheter is out of position d. The patient is developing an epidural catheter site infection 9. What is your treatment plan for this assessment? a. Neuro consult b. Page Pain Management Coordinator c. Increase CADD pump rate as per order d. Contact attending surgeon 10. What non-pharmaceutical modalities may help this patient? (Circle all that apply) a. Ambulate b. caffeine intake c. Hydrate d. Heat pack to back of head e. Darken room f. Bedrest (HOB elevation maximum of 30 degrees)

3 11. Anesthesia has decided to do a Blood Patch. What statement(s) is correct regarding this treatment? Circle all that apply a. May use 5-20 ml blood b. Provides a clot over the hole in the Dura to stop CSF leak c. Patient must remain supine for 4 hours after blood patch d. Blood is mixed with pain medication before insertion 12. A patient is Post-op day one, Radical Prostatectomy. Epidural meds are Bupivicaine 0.075% and Fentanyl 5 mcg/ml in 250 ml IV 5 ml/hr per CADD pump. VAS is 2 at rest. BP 124/52 supine, HR 68, RR 14, and Temp The patient is to ambulate for the first time. Your action: a. Assess patient s lower limb neuro status. Patient is able to lift legs off bed but indicates numbness in right thigh. You assist the patient to a sitting position and ask him to hold on to the IV pole as you proceed to ambulate. b. Maintain bedrest. Epidural therapy patients are not permitted to ambulate on post-op day one. c. Obtain an order to DC epidural catheter before ambulation d. Assess the patient s lower limb status including ability to lift legs off bed. There is no numbness or weakness in his legs and patient s BP in the sitting position is 120/ 60. You enlist the assistance of another person for the first ambulation. 13. Your patient is post-op day 3. During rounds the Anesthesia Pain Service writes an order to discontinue the epidural catheter. Darvocet N-100 is ordered Q4-6 hours prn for pain. Your action: a. Do not remove the catheter. Only a member of the Anesthesia Pain Service (APS) can discontinue the catheter b. Delegate the task to a nursing assistant c. Remove the dressing and tape. Cleanse the catheter and site well with alcohol. With the patient in a sitting position, pull on the catheter forcibly since a considerable amount of tension is required to remove the catheter. Apply a 4x4 over the site d. Loosen the tape and dressing carefully so as not to dislodge the catheter. Inspect the site for redness and swelling. Gently pull on the catheter applying steady tension. If resistance is met, stop and notify APS. If the catheter slides out easily, cleanse the site with alcohol and apply a bandaid. Note presence of black tip on catheter 14. Your patient is getting up to a chair at the bedside for the first time. Epidural is at 6ml/hr. BP 110/52 supine. After assisting the patient into a sitting position, you check the BP again. BP 78/38. The patient became diaphoretic and complained of dizziness. Your action: a. Assist the patient back into bed. Place her in a trendelenberg position and prepare a Dopamine drip b. Return the patient into a lying position with a pillow under his/her knees. Open IV s you may administer 500ml Normal saline over 30 minutes. Also consider administer Ephedrine 5-10mg IVP. If BP does not respond to fluids, call the Anesthesia Pain Service. c. Enlist the help of another nurse to get the patient into a chair. Place feet up on a stool and recheck the BP d. Return the patient to bed. Inform him/her you will attempt to get them up later. Reassure him that people experience decreased BP the first day after surgery and Recheck BP again in 30 minutes

4 15. Your patient is 8 hours post op. He is drowsy but arousable. When awakened he complains of pain with a VAS of 4. Standard epidural solution is infusing at 8ml/hr and Morphine Sulfate 4mg IVP has been given twice over the last 5 hours for breakthrough pain. He is unable to move his legs on command, however, moves is arms freely. No spontaneous movement of either leg is noted. Your action: a. Decrease the epidural solution by 1 hour b. Do nothing, wait until the patient is more awake to better evaluate the lower extremity status c. Stop the epidural infusion and notify Anesthesia Pain Service immediately d. Obtain an order to discontinue the Epidural catheter from the surgical resident so that another pain medication can be ordered 16. The most frequent side effects seen with Epidural therapy are: a. Itching, urinary retention and nausea/vomiting b. Rash, itching, paralysis c. Respiratory depression, hypotension, and nausea/vomiting d. Urinary retention, hematoma at the insertion site, nausea/vomiting 17. Your patient has an epidural solution infusing at 8ml/hr with a VAS 2 at rest and VAS 4 with activity. Temperature Post op day #3. The surgical resident orders to discontinue the epidural therapy and PCA morphine per protocol. Your action is to: a. Discontinue the epidural catheter and initiate the PCA therapy when the equipment is available b. Increase the epidural rate by 1ml and give breakthrough pain medication for the VAS of 4 c. Call for the PCA medication stat and discontinue the epidural when the alternate pain therapy is available and ready to be started d. Call Anesthesia Pain Service to evaluate the patient. If an order to discontinue is obtained from Anesthesia Pain Service, then discontinue the epidural catheter and initiate the PCA as ordered 18. After the epidural catheter is discontinued, charting on the Pain Management Flow Sheet must include: a. Time and date of removal, presence of a tip (blue/black/silver), description of site noting any redness, drainage or swelling, narcotic waste, that is documented by yourself and another nurse b. Waste is documented on the narcotic audit sheet only. Document date and time of catheter removal c. VAS at rest and with activity. Lower extremity sensation and motor strength. Alternative pain management ordered, and the time and date of removal d. Vital signs, including BP sitting and supine, amount of narcotic waste, documented by two nurses, and the date and time of removal 19. When placed correctly, the epidural catheter is : a. In the space between the bony vertebral canal and the dura. This space contain fat, blood vessels, and nerves b. In the lateral horn of the spinal cord c. Through the dura in the cerebral spinal fluid d. Only at the lumbar level

5 20. Your patient is preparing to get out of bed and his epidural catheter becomes tangled in the bed rails. The catheter becomes disconnected. Your action is: a. After wiping each end with alcohol, reconnect the tubing b. You cover the epidural port with a sterile 4x4 gauze and call the anesthesia Pain Service to obtain an order to D/C the catheter c. Reconnect immediately, do not wipe with alcohol because it is neurotoxic d. Cap the epidural port and obtain an alternate pain management therapy order from the surgical resident 21. Your patient is receiving an epidural solution at a rate of 10ml/hr. When doing your hourly vital sign checks, he is found to be lethargic, BP 106/54, HR 64, RR 6. Respirations are shallow and irregular. Your action: a. Decrease the epidural catheter rate to 5ml/hr. Call Respiratory therapy STAT for an oxygen mask set-up. When the patient is more alert, you may resume increasing rate PRN for a VAS >5 b. Stop the epidural infusion. Prepare the dilute narcan solution and call the house officer to obtain the order to administer c. Begin CPR and and ask another nurse to call for the rapid response team d. Stop the epidural infusion, prepare Narcan by diluting and administer 0.1mg IVP q 2-3 minutes: up to 0.4mg maximum, or until the patient responds with a RR > 10 bpm. Notify Anesthesia Pain Service 22. Your patient has a nerve block with Bupivicaine 0.20% running at 8ml/hr s/p a right shoulder rotator cuff repair. She complains of an inability to control her arm. Your action is: a. Turn down the rate to 7ml/hr b. Stop the infusion pump and notify Anesthesia Pain Service immediately c. Remove the catheter d. Explain that this is a normal response and ensure that the patient is safe, perhaps with an arm sling. You may turn the rate down PRN until motor function returns 23. Your patient is POD #2. VAS is 1 at rest and VAS 2-3 with activity, especially coughing or deep breathing. The Epidural solution is infusing at 4ml/hr. The infusion site and system checks are O.K. Vital Signs are stable and no other side effects are noted. Your action: a. Offer breakthrough pain medication when patient is getting ready to ambulate b. No action is necessary. Continue the present Epidural infusion rate c. Increase the epidural to 6ml/hr, prior to ambulating the patient and when patient returns to bed, decrease him/her back to 4ml/hr d. Decrease the epidural to 3ml/hr, and begin the weaning process 24. Your patient is receiving an Epidural infusion at 3 ml/hr. The patient is now restless, confused and disoriented. He is attempting to remove the tape and dressing from his back and had pulled out his IV which was then restarted. His last dose of heparin was approximately 1 hour ago. You action: a. Decrease the epidural rate to 2ml/hr and restrain the patient b. No action necessary c. Increase the epidural rate, the patient appears to be in a great deal of pain d. Stop the infusion and assign a person to stay with the patient. Notify APS

6 25. Assessment of the Bromage scale includes which of the following? a. Grip strength b. Level of consciousness c. Leg lift d. VAS 26. The major advantage of delivering narcotics via epidural is that they: a. Increase patient alertness b. Reduce pulmonary complications c. Contribute to earlier ambulation d. All of the above 27. True False Itching due to histamine release is inevitable with epidural therapy so all patients are placed on Benadryl IVP every 6 hours for relief 28. True False Pain is subjective. Only the person experiencing it knows how much it really hurts 29. True False Per Policy, only an epidural certified RN can take care of a patient receiving epidural therapy 30. True False If your patient is itching, standard epidural orders allow you to give one ampule (0.4mg) of Narcan IVP undiluted