After a left total-knee replacement, Elaine Lee, age 58, is receiving a femoral perineural infusion of ropivacaine, a local anesthetic. On her first morning postoperatively, her pain rating is low, but her left leg is weak and she can’t participate in physical therapy. Her nurse decreases the infusion rate, as prescribed, and within 2 hours, the weakness resolves. For the next 2 days, Ms. Lee participates in physical therapy. On her third postoperative day, her nurse stops the infusion, administers oral analgesics, and monitors her pain rating, as ordered. The ratings remain stable for 4 hours, and the nurse removes the perineural catheter, following hospital protocol. The next morning, Ms. Lee is discharged with a prescription for an oral analgesic.
This case history may seem unremarkable today, but consider how Ms. Lee’s pain would have been controlled 20 years ago when analgesics were typically delivered only by the oral and intramuscular routes. Now, we have many more—and more effective—options. We can use catheter techniques to deliver epidural, intrathecal, interpleural, and perineural analgesia and local anesthesia. And as the options for pain management have increased, so has the role of nurses. (See Common catheter techniques for analgesia in PDF by clicking the download now button.)
Defining the role of nurses
In 1991, in response to the increasing use of epidural analgesia, the American Nurses Association published a position statement saying that administering analgesia is within the registered nurse’s (RN’s) scope of practice. Because of the continuing evolution of analgesic techniques, the American Society for Pain Management Nursing (ASPMN) published an updated position statement in 2002.
The ASPMN statement asserts that RNs, because of their assessment abilities, knowledge of infusion devices, and 24-hour presence, are essential to the safe delivery of analgesia by catheter techniques. The guidelines in the statement apply to the care of all patients in all settings. However, the ASPMN statement acknowledges that the RN’s role in managing and monitoring analgesia administration is defined by a nurse’s state board of nursing. Also, other nursing organizations, such as the Association of Women’s Health, Obstetric, and Neonatal Nurses, may hold different opinions on the RN’s role, which need to be considered.
Because different patients experience pain differently, therapy should be tailored to each patient’s need. The widespread use of patient-controlled analgesia by the oral, I.V., epidural, and now perineural routes in pediatric, geriatric, labor, oncology, and surgical patients confirms the value of personalized pain therapy. And the need for tailored therapy underscores the appropriateness of having nurses monitor and manage patients receiving analgesia by catheter techniques.
According to the ASPMN guidelines, to care for these patients, RNs must:
• complete educational requirements established by the institution (See What nurses must know in PDF by clicking on the download now button.)
• follow institutional policies, procedures, and guidelines
• communicate with the licensed independent practitioner on patient status during therapy
• document therapy based on the institution’s policies, procedures, and guidelines
• participate in quality improvement activities as required by the institution.
Monitoring and managing therapy
Only licensed independent practitioners who are trained and authorized may place a catheter or infusion device, administer a test dose to confirm catheter or infusion-device placement, and establish an analgesic dosage.
After the catheter is in place and the dosage is prescribed, the patient’s nurse monitors his status by performing regular, systematic assessments that address the following:
• pain level
• vital signs, plus oxygen saturation and carbon dioxide levels, if prescribed
• sedation level, if the patient is receiving an opioid
• fetal status and response to therapy, if the patient is in labor
• adverse effects, motor and sensory deficits, and complications
• infusion system.
In the course of managing the patient’s care, a nurse may perform these interventions:
• injecting a bolus of analgesia after a therapeutic range is established
• adjusting the infusion rate in compliance with the licensed independent practitioner’s orders
• treating adverse effects and complications
• replacing empty drug reservoirs
• refilling implanted drug reservoirs
• troubleshooting the infusion device
• changing the infusion-device batteries, tubings, and dressings
• discontinuing therapy based on a licensed independent practitioner’s orders.
If institutional policy and state law allow, a qualified nurse may also remove the catheter, as ordered by a licensed independent practitioner.
More choices, more responsibilities
Advances in technology and research have led to important, new ways of delivering analgesics over the last two decades. Along with those advances have come new responsibilities and opportunities for nurses in virtually all settings. With a little extra education and training, you can expand your scope of practice and help ease your patients’ pain in the most effective way at the same time.
American Nurses Association. Position Statement on the Role of the Registered Nurse (RN) in the Management of Analgesia by Catheter Techniques (Epidural, Intrathecal, Intrapleural, or Peripheral Nerve Catheters). Washington, DC: American Nurses Association; 1991.
Krenzischek D, Wilson L. Introduction to the ASPAN pain and comfort clinical practice guideline. J Perianesth Nurs. 2003;18(4):228-231.
Pasero C. Epidural Analgesia for Acute Pain Management. Self-Directed Learning Program. Lenexa, KS: American Society for Pain Management Nursing; 2003.
Pasero C. Perineural local anesthetic infusion. Am J Nurs. 2004;104(7):89, 91-93.
Pasero C, Eksterowicz N, Primeau M, Cowley C. Registered nurse management and monitoring of analgesia by catheter techniques [position statement]. Pain Manag Nurs. 2007;8(2):48-54. www.aspmn.org/Organization/documents/RegisteredNurseManagementandMonitoringofAnalgesia.pdf. Accessed August 27, 2008.
Visit www.AmericanNurseToday/journal for a complete list of selected references.
Chris Pasero is a pain-management educator and clinical consultant in El Dorado Hills, California. Nancy Eksterowicz is an Advanced Practice Nurse I for Pain Services at the University of Virginia Health System in Charlottesville and President Elect of the American Society for Pain Management Nursing. Maggie Primeau is Associate Vice President at Southern New Hampshire Medical Center in Nashua. Charlene Cowley is the Pain Management Nursing Coordinator at Phoenix Children’s Hospital in Phoenix, Arizona.