7/26/2014 RE: Epidural Monitoring - Davis, Aurora

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RE: Epidural Monitoring
Aurora,
I agree with Annsley that including that "the Dashboard has a reference for Moline Roberts
and dermatomes" is a good addition.
You are right in that we can not delegate sedation to a CNA, this check needs to be done by an RN. So no
need to add:)
The only other thing I saw is that Sedation Level 2 on Moline Roberts is NOT the same as the order set
which it looks like you referenced. Perhaps until that all gets worked out you should just state words rather
than the number!
Lastly, please but your initials and FY14 on the bottom so we know this is current!!!
Thanks Aurora,
Kyle Rose Hammond RN, BSN, OCN
Clinical Nurse Educator
Oncology and Bone Marrow Transplant
kyle.hammond@UCHealth.org
720-848-0422


From: Davis, Aurora
Sent: Sunday, April 27, 2014 9:36 AM
To: Buffington, Annsley J; Johnson, Mandy; Hammond, Kyle R
Subject: RE: Epidural Monitoring

Annsley,

The dermatome guide will definitely be referenced. However, I don't believe we can delegate the Q1H
RR/sedation. Even though the CNAs can check respirations, I don't think they can do sedation. Correct?

Aurora


Hammond, Kyle R
Sun 4/27/2014 9:47 AM
To:Davis, Aurora <Aurora.Davis@uchealth.org>; Buffington, Annsley J <Annsley.Buffington@uchealth.org>; Johnson, Mandy
<Mandy.Johnson@uchealth.org>;
7/26/2014 RE: Epidural Monitoring - Davis, Aurora
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Aurora Davis, RN, BA, BSN, OCN
Relief Charge Nurse
Oncology and Bone Marrow Transplant Unit
University of Colorado Hospital
Aurora.Davis@uchealth.org
From: Buffington, Annsley J
Sent: Sunday, April 20, 2014 9:44 PM
To: Davis, Aurora; Johnson, Mandy; Hammond, Kyle R
Subject: RE: Epidural Monitoring

Thanks Aurora for updating and putting this together! My only thought is to perhaps make a note that the
Q1h RR and BP/HR can be a coordinated/shared task with CNA/ACPs, ie odd vs even hours. Perhaps also
make a reference that the dermatome assessment reference can be found on the EPIC dashboard. Thanks!
Annsley J Buffington RN, BSN, OCN
Clinical Nurse Educator
Oncology, Bone Marrow Transplant, Gyn-Onc
720-848-4940
Annsley.Buffington@uchealth.org

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From: Davis, Aurora
Sent: Friday, April 18, 2014 9:10 AM
To: Johnson, Mandy; Hammond, Kyle R; Buffington, Annsley J
Subject: Epidural Monitoring


Ladies,

Per Mandy's request, here's a teaching email on epidurals. For your approval prior to distribution to the
units.

Thanks,
Aurora


----------------------------------------------------------------------------------------------
Fabulous people,

I heard through the grapevine that folks might need a little refresher on how to monitor epidural infusions.
It's true, we don't get a lot of them up on this unit, so here's a brief overview.

1) Monitoring is similar to PCA monitoring, with the addition of dermatomes, motor strength, and
catheter site Q4H. This means you should monitor and chart RR and sedation rate Q1H x 12H, Q2H x 12H,
then Q4H for the remainder of the time they have an epidural. But you must ALSO monitor (and chart) pt's
7/26/2014 RE: Epidural Monitoring - Davis, Aurora
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dermatomes, motor strength, and epidural catheter insertion site Q4H. What does that mean? Well...

2) Q4H Dermatome monitoring. Anyone remember dermatomes? A dermatome is the area of skin
covered by a single spinal nerve. If an area of skin is numb, it correlates to the innervation of a specific
spinal nerve. There's a dermatome cheat sheet (affectionately referred to as the Dermatome Man) on your
EPIC dashboard under UCH-Central-->Guide-->Dermatome Guide. This guide shows you which areas of
skin are associated with particular spinal nerves.

How do you test if an area of skin is numb? Ice! Ice, my friend, a small amount in a plastic baggie placed
right on the skin of the torso. Start at the umbilicus on one side of the torso and move up. When the
patient says they can feel cold, that's the dermatome level. Do the same thing on the oher side of the
torso, starting at the umbilicus and moving up. Then, repeat on each side of the torso, this time moving
down from the umbilicus. Dermatome monitoring can be added and charted under the Pain/Med Mgt tab
on EPIC.

So what's the big deal with dermatomes? Why do we monitor them? Changes in dermatome level can
indicate that an epidural has migrated. That means it may become less effective at controlling your
patient's pain. On the other hand, it could become too effective and migrate to an area that means it
interferes with respiratory function. If your dermatomes are above the nipple line, you should notify the
Acute Pain Service immediately!

3) Q4H Motor strength monitoring. You need to assess limb strength Q4H to look for any sudden
weakening of an arm or leg that might indicate epidural migration. This is also found under the Pain/Med
Mgt tab.

4) Q4H Epidural Catheter site montoring. Epidurals can be pulled out just like IVs, and therefore, the site
needs to be monitored and charted on just like an IV. You can add the epidural site charting under the
Pain/Med Mgt tab.

5) APS--the Acute Pain Service--owns all epidurals and is your go to resource for epidural questions
and problems. If you have issues with pain control and the patient is on an epidural, APS should be your
first call. They are the ones who decide if the patient gets changes on their epidural or additional
narcotics. They should also be notified of problems like decreased RR, oversedation, weakness in
extremities, dermatomes above the nipple line, or compromised epidural sites.

A Back to the Basics tip sheet on Epidurals is attached.

Questions? Comments? Let me know!

Aurora

Aurora Davis, RN, BA, BSN, OCN
Relief Charge Nurse
Oncology and Bone Marrow Transplant Unit
University of Colorado Hospital
Aurora.Davis@uchealth.org