A priority nursing intervention when caring for a client who is receiv

A priority nursing intervention when caring for a client who is receiving an epidural infusion for pain relief is to:

1. Use aseptic technique
2. Label the port as an epidural catheter
3. Monitor vital signs every 15 minutes
4. Avoid supplemental doses of sedatives

ANSWER

ANS: 3
When clients are receiving epidural analgesia, monitoring occurs as often as every 15 minutes, including assessment of respiratory rate, respiratory effort, and skin color. Complications of epi-dural opioid use include nausea and vomiting, urinary retention, constipation, respiratory depres-sion, and pruritus. A common complication of epidural anesthesia is hypotension. Assessing vital signs is the priority nursing intervention. Because of the catheter location, strict surgical asepsis is needed to prevent a serious and potentially fatal infection. To reduce the risk for accidental epi-dural injection of drugs intended for IV use, the catheter should be clearly labeled “epidural catheter.” Supplemental doses of opioids or sedative/hypnotics are avoided because of possible additive central nervous system adverse effects.