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Home , Brachial plexus block, Infusion pump, Nerve block

PROCEDURE Peripheral Blocks : 107 Assisting with Insertion and

Kimberly Williams PURPOSE: Peripheral nerve blocks are administered as single injections or continuously through a placed into a precise anatomical area to provide site-specifi c analgesia or .

PREREQUISITE NURSING • The anatomical position of the specifi c catheter should be KNOWLEDGE clearly defi ned and documented after insertion by the phy- sician or advanced practice nurse (e.g., femoral, axillary • State boards of nursing may have detailed guidelines [ Figs. 107-1 and 107-2 ], [ Fig. 107-3 ], involving peripheral nerve blockade. Each institution that intrapleural, extrapleural, paravertebral, tibial, sciatic, provides this therapy also has policies and guidelines per- lumbar plexus). 5,32 Radiological confi rmation 6 of the cath- taining to peripheral nerve blockade. It is important that eter position may be necessary to avoid suboptimal out- the nurse is aware of state guidelines and institutional comes (e.g., ). may be placed by policies.15 the surgeon, anesthesiologist, or certifi ed • The nurse must have an understanding of the principles under direct vision, via ultrasound scan–guided tech- of aseptic technique.9,12,19,23,39 niques or with the use of a peripheral nerve stimulator, • The nurse assisting with the insertion of peripheral nerve either adjacent to or directly into the nerve sheath (e.g., blocks requires specifi c skills and knowledge.15 sciatic or tibial nerve during for lower-limb ampu- • Catheter placement and management of the patient should tation). 16,19,21,23,29,31 Catheters may also be placed after be under the direct supervision of an anesthesiologist, surgery (e.g., intercostal, intrapleural, axillary, brachial nurse anesthetist, or the acute pain service. 24,26,39 Periph- plexus, femoral, paravertebral; Table 107-1 ). eral nerve blocks are used as part of a preemptive and • A three-in-one peripheral can be used for multimodal technique to provide safe and effec- analgesia after proximal lower-limb orthopedic surgery. tive postoperative pain management with minimal side A three-in-one peripheral nerve block provides analgesia effects.10,12,14,18,21 to block three , including the lateral femoral cuta- • Peripheral nerve blocks are site specifi c (e.g., femoral, neous, femoral, and obturator nerves. 4,26 This block is as brachial plexus, axillary, intrapleural, extrapleural, para- effective as epidural analgesia, with fewer side effects vertebral, tibial, sciatic, lumbar plexus) and provide pro- than epidural analgesia (e.g., urinary retention, nausea, longed anesthesia or analgesia for postoperative and risk for epidural hemorrhage in patients with anticoagula- trauma pain management.4,26 tion). 6,7,16,26,27 Some forms of plexus analgesia (e.g., bra- • Peripheral nerve blocks in the outpatient setting have chial plexus analgesia) in the postoperative setting may facilitated early patient ambulation and discharge by serve two purposes: pain relief and sympathetic blockade, decreasing side effects, such as drowsiness, nausea, and the latter of which increases blood fl ow and may improve vomiting.3,11,13,18 In addition, unlike general anesthesia, outcomes in some cases (i.e., digit reimplantation).5,16,23,34 peripheral nerve blocks do not directly alter the level of • Analgesia via a catheter may be administered as a continu- consciousness. By preserving the patient ’ s level of con- ous infusion with the use of a volumetric pump system, sciousness, the patient’ s protective airway refl exes (e.g., a patient-controlled regional infusion system, or a dis- cough and gag) are maintained and the need for airway posable pump device (e.g., elastomeric). An elastomeric manipulation and intubation is negated. Furthermore, with pump is one type of disposable designed to the use of peripheral nerve blockade, the complications provide a constant rate of infusion from a fi lled reservoir. of general anesthesia are avoided. 3 Continuous periph- The infusion rates may or may not be adjustable ( Fig. eral nerve blockade improves postoperative analgesia, 107-4 ). 21,30,34 administered is usually a local patient satisfaction, and rehabilitation compared with anesthetic (e.g., , ropivacaine). Other agents intravenous (IV) for upper- and lower-extremity have been used on an adjunctive basis as a , includ- procedures.11,13,18,26,31 ing opioids, clonidine, epinephrine,16,17 and neostigmine. 18

948 107 Peripheral Nerve Blocks: Assisting with Insertion and Pain Management 949

Axillary muscle Median nerve

Axillary fascia Ulnar nerve

Figure 107-1 Location for needle insertion for an axillary block. (From Sinatra RS: Acute pain: Mechanisms & management , St Louis, 1992, Mosby.)

Midclavicular point

Infraclavicular site

Axillary artery

Figure 107-2 Needle insertion for an axillary block. (From Sinatra RS: Acute pain: Mechanisms & management , St Louis, 1992, Mosby.)

• The pharmacokinetics and pharmacodynamics of local concentration of the medication, site of injection, and anesthetics and other agents used, including side effects absorption. The addition of a vasoconstrictor, such as epi- and duration of action, should be clearly understood. nephrine, constricts blood vessels and reduces vascular Local anesthetic used for peripheral nerve uptake, which further prolongs the duration of action of blocks provide surgical analgesia (i.e., loss of pain sensa- the local anesthetic.16,17 Epinephrine is not recommended tion) and anesthesia (i.e., loss of all sensation). The dura- with peripheral nerve blocks in areas with end , tion of action for each anesthetic medication depends such as ear lobes, the nose, digits, and the penis.39 Vaso- on several factors, including the volume injected, constrictor medications may cause spasm of blood vessels, 950 Unit III Neurologic System

External jugular vein

Middle scalene muscle

Trunks of the Cricoid brachial plexus cartilage

Subclavian artery Anterior scalene muscle Figure 107-3 Landmarks for interscalene . (From Sinatra RS: Acute pain: Mechanisms & management , St Louis, 1992, Mosby.)

TABLE 107-1 Single-Shot (One-Time, Single Injection) and Continuous Peripheral Nerve Blocks Block Indications Practical Problems Interscalene Shoulder/arm pain (e.g., shoulder dislocation/fractures, humeral • Horner ’ s syndrome may obscure neurological fracture) assessment • Block of ipsilateral • Close proximity to tracheostomy and jugular vein line sites Cervical Shoulder/elbow/wrist pain (e.g., shoulder fractures, humeral • Horner ’ s syndrome may obscure neurological paravertebral fracture, elbow fractures, wrist fractures) assessment (continuous • Block of ipsilateral phrenic nerve catheter only) • Patient positioning Infraclavicular Arm/hand pain (e.g., elbow fractures, wrist fractures) • Pneumothorax risk • Steep angle for catheter placement • Interference with subclavian lines Axillary Arm/hand pain (e.g., elbow fractures, wrist fractures) • Arm positioning • Catheter maintenance Intercostal Blockade used for management of pain due to traumatic rib • Catheter malposition fractures. Commonly an elastomeric infusion pump, which is a • Risk of pneumothorax balloon fi lled with local anesthetic attached to a catheter placed at the site of injury. This delivery system results in slow infusion of local anesthetic for pain control. This provides pain relief so that patients are able to ventilate more effectively. Paravertebral Unilateral chest or abdominal pain restricted to a few • Patient positioning dermatomes (e.g., rib fractures) • Stimulation success sometimes hard to visualize Combination of Unilateral leg pain (e.g., femoral neck fracture [femoral], tibial • Patient positioning femoral and and ankle fractures [sciatic])* • Interference of femoral nerve catheters with sciatic block femoral lines

* Caution: Compartment syndrome. Modifi ed from Schulz-Stubner S: The critically ill patient and regional anesthesia, Curr Opin Anaesthesiol 19:538–544, 2006. 107 Peripheral Nerve Blocks: Assisting with Insertion and Pain Management 951

• Pump for administration of analgesia (e.g., volumetric pump, dedicated for peripheral nerve block infusion with rate and volume limited, and preferably a different color from the epidural and IV infusion pumps; patient-controlled analgesic pump or a portable infusion device such as a disposable elastomeric continuous infusion pump • Specifi c observation chart for patient of the peripheral nerve block infusion • Prescribed and local anesthetics • Equipment for monitoring blood , heart rate, and pulse oximetry Additional equipment, to have available as needed, includes the following: • Ice or alcohol swabs for demonstrating sensory block Figure 107-4 An elastomeric infusion pump. Parts include 1, • Emergency medications (e.g., 20% fat /intralipids fi lling ; 2, elastomeric balloon (drug-containing reservoir); and for local anesthetic toxicity) 3, outer protective shell. (Originally published in Skryabina E, • Bag-valve-mask device and oxygen Dunn TS: Disposable infusion pumps, Am J Health Syst Pharm • Equipment for end-tidal carbon dioxide monitoring 63:1260-1268, 2006.) © 2006, American Society of Health-System • Intubation equipment Pharmacists, Inc. All rights reserved. Reprinted with permission (R1002). • Peripheral nerve stimulator and/or ultrasound to facilitate placement resulting in necrosis.9 Knowledge of signs and symptoms of profound motor and sensory blockade, or overmedica- PATIENT AND FAMILY EDUCATION tion, is essential.5,9,10,17 • Sensory and motor blockade may be acceptable or desir- • Explain the reason and purpose of the catheter. If avail- able, depending on the goals and preferences of the inter- able, supply easy-to-read patient information. Rationale: disciplinary team. The loss of sensation at the site is often The patient and the family know what to expect; the primary goal of blocks, and although motor loss is may be reduced. often acceptable, it is not desirable.3 • Explain to the patient and family that the procedure can • Relative contraindications to peripheral nerve blockade be uncomfortable but that a local anesthetic will be used include a history of coagulopathy, preexisting neuropa- to facilitate comfort. Rationale: Explanation elicits the thies, anatomical or pathological deviations at the injec- patient ’ s cooperation and comfort, and facilitates inser- tion site, and systemic disease or . 5,7,10,22,26,27,39 tion; anxiety and fear may be decreased. • Local anesthetic toxicity can result from inadvertent injec- • During therapy, instruct the patient to report side effects tion of local anesthetic into the vascular system or rapid or changes in pain or sensation. Observe for suboptimal absorption of the agent from the tissue into the vascular analgesia, profound numbness of extremities (beyond the system. Intralipids/20% fat emulsion should be immedi- goal of therapy), patient report of lightheadedness, metal- ately available for IV infusion, to help restore cardiovas- lic taste, circumoral numbness, dizziness, blurred vision, cular stability.8 tinnitus, loss of hearing, and .5,9,17,23 Rationale: Reporting of pain aids the patient ’ s comfort level and EQUIPMENT identifi es side effects. Recognition of early signs and symptoms of local anesthetic toxicity can prevent cardiac • One peripheral nerve catheter kit , arrest, and death. • Infusion set for continuous plexus anesthesia with or • Teach the patient to protect the affected extremity from without an adaptor for a nerve stimulator injury and trauma (e.g., burns). 3,5,23 Rationale: Patient • Peripheral nerve stimulator safety is increased, and the limb is protected from injury • Topical skin antiseptic, as prescribed and trauma. • Sterile towels • If a volumetric pump for patient-controlled regional anal- • Sterile forceps gesia (PCA) is used, educate the patient and family on its • Sterile gauze 4 × 4 pads use. Reinforce this education throughout the duration of • Sterile gloves and gowns regional PCA therapy. Rationale: This may decrease • Fluid shield face masks anxiety and assists the patient in effectively using the • 20-mL normal infusion system. • 5- to 10-mL local anesthetic as prescribed (1% lidocaine) for local infi ltration PATIENT ASSESSMENT AND • Local anesthetic as prescribed (to establish the block) PREPARATION • Occlusive dressing supplies to cover the catheter entry site • Gauze and tape to secure the catheter to the patient’ s body Patient Assessment • Labels stating “Local anesthetic only” and “Not for intra- • Observe the patient for signs and symptoms of local infec- venous injection” tion or generalized sepsis. Rationale: This decreases the 952 Unit III Neurologic System

risk for infection at the site of catheter insertion. Septi- cemia and bacteremia are contraindications for periph- Patient Preparation eral nerve block catheter placement or continuation of • Verify that the patient is the correct patient using two therapy. 10,12 identifi ers. Rationale: Before performing a procedure, the • Assess the patient ’ s concurrent anticoagulant and fi brino- nurse should ensure the correct identifi cation of the patient lytic therapy.6,7,39 Rationale: Heparin (unfractionated and for the intended intervention. low–molecular-weight heparin), heparinoids, and fi brino- • Ensure that the patient and family understand the planned lytic agents administered concurrently increase the risk procedure. Answer questions as they arise, and reinforce for vessel trauma (e.g., hematoma). Care must be taken information as needed. Rationale: Understanding of pre- with insertion and removal of the peripheral nerve block viously taught information is evaluated and reinforced. catheter when patients are on anticoagulant and fi brino- • Ensure that informed consent has been obtained. Ratio- lytic therapy.9,27 Special institutional guidelines must be nale: Informed consent protects the rights of the patient observed.3,5–7,19,25,27 Insertion and removal of the peripheral and makes a competent decision possible for the patient. nerve catheter should be directed by the physician or • Perform a preprocedure verifi cation and time out, if non- advanced practice nurse. 5–7,27 emergent. Rationale: This ensures patient safety. • Obtain the patient ’ s vital signs. Rationale: This provides • Wash the specifi c anatomical area of the patient ’ s body baseline data. with soap and water, and open the gown to expose the site • Assess the patient ’ s pain and anxiety. Rationale: This for injection while maintaining the patient ’ s privacy and provides baseline data and helps determine whether pre- dignity. Rationale: This action cleanses the skin and medication is required. allows easy access to the specifi c anatomical area of the • Reassure the patient. Rationale: Anxiety and fears may patient ’ s body. be reduced. • Establish IV access or ensure the patency of IV catheters. • Review the patient ’ s medication allergies. Rationale: Rationale: Medications may be needed if side effects Review of medication allergies before administration of a occur (i.e., ). new medication decreases allergic reactions. • Position the patient as appropriate, according to which • Consider instructions for nothing by mouth, especially if anatomical area of the body is to be blocked. Rationale: or general anesthesia is to be used. Rationale: This prepares the patient for the procedure. The risk for vomiting and aspiration is decreased.

Procedure for Peripheral Nerve Blocks Steps Rationale Special Considerations 1 . HH 2 . PE Physicians, advanced practice nurses, and other healthcare professionals should apply personal protective gear (e.g., face masks with eye shields) and sterile attire (e.g., sterile gowns, sterile gloves). 3. Obtain the prescribed peripheral The medication should be prepared All peripheral nerve block nerve block medication. with aseptic technique by the are preservative free to avoid pharmacy with laminar fl ow or neuronal injury.7 prepared commercially. 4. Connect the correct tubing to the Removes air from the infusion prepared infusion and prime the system. tubing. 5. Ensure that the patient is in Facilitates ease of insertion of the Assist with holding the patient in position for catheter placement. peripheral nerve block catheter. position or consider sedation, if necessary. 6. Assist as needed with the Reduces the transmission of The choice of povidone-iodine or antiseptic preparation of microorganisms into the nerve chlorhexidine as an antiseptic agent the intended insertion site. sheath or plexus space. 12,23 for neurological procedures is (Level C * ) controversial. Both should be allowed to dry completely. Chlorhexidine may be neurotoxic.20 7. Assist if needed with draping the Aids in maintaining sterility. patient with exposure of the insertion site.

* Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. 107 Peripheral Nerve Blocks: Assisting with Insertion and Pain Management 953

Procedure for Peripheral Nerve Blocks—Continued Steps Rationale Special Considerations 8. Assist the physician or advanced Facilitates catheter insertion. Use of a Ultrasound guidance may be used to practice nurse as needed with the peripheral nerve stimulator assists place the continuous peripheral catheter placement and with identifi cation of the nerve.23,28 nerve block catheter. If ultrasound manipulation of the controls on has print capability, print a reading the peripheral nerve stimulator if and include it in the chart for used). 3,23 (Level C * ) documentation. 9. After the peripheral nerve Reduces the incidence of infection.12,23 catheter is inserted, assist as needed with the application of a sterile, occlusive dressing. 10. Secure the fi lter to the patient ’ s Avoids disconnection between the body with a gauze padding and peripheral nerve catheter and the tape. fi lter. The gauze padding prevents discomfort and skin pressure from the fi lter. 11. The physician or advanced Facilitates a therapeutic level of An initial test dose of local anesthetic practice nurse will administer a analgesia and ensures correct agent with or without epinephrine bolus dose of medication via the catheter placement. 39 may be administered, then a bolus catheter. dose. Monitor vital signs and symptoms of local anesthetic toxicity and assess the patient’ s pain. Emergency medications and equipment must be available.7,25 12. Connect the prescribed Prepares the infusion system. medication infusion system. 13. Initiate therapy: A. Place the system in a Prepares the infusion system. Responses to peripheral nerve block volumetric pump or analgesia vary individually, and elastomeric continuous analgesia is tailored according to infusion pump and set the rate individual responses. Note: and volume to be infused as Peripheral nerve catheters may also prescribed. be attached to a portable disposable infusion device (e.g., elastomeric pump) 16,21,30,35 that may not have an adjustable rate or volume.30,35 B. Attach a label: “Local Do not give any other solution or anesthetic only—Not for medication via this catheter. intravenous injection” to the Inadvertent administration of some IV tubing and use a portless medications into the peripheral system. 5 (Level D * ) nerve block catheter may cause nerve or tissue damage. Inadvertent administration of local IV anesthetic can cause hypotension and cardiovascular collapse or arrest. 17,21,23 C. Lock the key pad on the Prevents inadvertent or accidental volumetric pump. changes in therapy. 14. Continue to assess the quality of Identifi es patient comfort level and is the analgesia. an indicator to clinicians regarding the effectiveness of the therapy.

*Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. * Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

Procedure continues on following page 954 Unit III Neurologic System

Procedure for Peripheral Nerve Blocks—Continued Steps Rationale Special Considerations A. Determine the patient ’ s pain The amount of pain experienced by based on a consistent and the patient should be no more than reliable pain-assessment tool the amount of what is acceptable according to institutional to the patient.1,2,9 policy. 33 B. Assist as needed with testing The ideal peripheral nerve block the corresponding dermatome should be just above and just below level of the peripheral nerve the (anticipated) surgical incision or block with ice or an alcohol the trauma site (see the dermatomes swab. described in Fig. 107-3 ).9,23 15. Remove PE and discard used Removes and safely discards used supplies in an appropriate supplies. receptacle. 16. HH

Expected Outcomes Unexpected Outcomes • Regional analgesic catheter inserted; accurate catheter • Inability to insert the catheter placement confi rmed with use of ultrasound scan, • Untimely or erroneous medication administration5,9 nerve stimulator, or radiological imaging when • Suboptimal analgesia appropriate5,6,18,22,29,31 • Adverse medication reactions not recognized • Pain minimized or relieved3,31,32 • Altered skin integrity from decreased sensory and • No patient oversedation or respiratory depression5,17,39 motor loss6,9,16,37,38 • Reduced need for parenteral opioids, thereby also • Accidental dislodgment of the catheter delivery reducing side effects18,23 system • Potential for reduction in states, • Leakage from the catheter insertion site especially after limb amputation14 • Cracked fi lter on the delivery system • Temporary numbness and loss of motor control23 • Inadvertent injection into a blood vessel3,5,39 • Ipsilateral Horner ’ s syndrome—symptoms that arise when a group of nerves known as the sympathetic trunk is damaged or blocked by anesthetic during block.26,36 Horner ’ s syndrome may also develop due to inadvertent vascular puncture and hematoma formation in the neck.4,26 The signs and symptoms occur on the same side as the affected sympathetic trunk (ipsilateral). Miosis (a constricted pupil), ptosis (drooping eyelid), and anhidrosis (decreased sweating) can occur. Enophthalmos (inset eyeball) may also be present, as may hoarseness5,26,36,39 • Nerve or vessel trauma3,5,39 • Hemorrhage or hematoma6 • Respiratory distress related to phrenic nerve paralysis, pneumothorax, or medication effect3,16,23,32 • Local infection at the peripheral nerve block catheter insertion site • Sepsis 12 • Anaphylaxis5,17 • Permanent neurological injuries and damage from insertion 26,39 • Systemic toxicity from local anesthetics (e.g., tachycardia, hypotension, metallic taste, blurred vision, circumoral numbness, tinnitus, decreased hearing, dizziness, confusion progressing to seizures, , or even death) 5,17,23 107 Peripheral Nerve Blocks: Assisting with Insertion and Pain Management 955

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions . 1. Assess the patient ’ s level of pain Identifi es the need for pain • Continued pain despite pain with a valid and reliable pain interventions. Describes the interventions scale. Follow institutional patient ’ s response to pain therapy. A standards for assessing pain. lower pain score is expected. Administer analgesia as Assessing and reassessing pain in prescribed. Continue to assess an objective manner helps frequently, especially during the determine appropriate treatment fi rst 12–24 hours of therapy.2,9,23,33 measures. 2. Assess the patient ’ s vital signs, Hypotension and sedation may refl ect • Change in respiratory status or oxygenation and ventilatory IV infusion, systemic toxicity, or other vital signs (e.g., respiratory status, and level of sedation with the residual effects of sedation rate, oxygenation via pulse a valid and reliable sedation administered for catheter oximetry, ) scale. 15,33 Monitoring the patient placement.21,23 • Altered level of consciousness every 15 minutes has been recommended in the immediate period after initiation of therapy.23 3. Assess the levels of motor and Ensures effectiveness of analgesia and • Signs and symptoms of sensory blockade. Follow maintenance of the block at the overmedication: institutional standards for these correct level. • Decreased ability to feel or to assessments (see Fig. move area of the body where 107-3 ). 1–3,9,23 the peripheral nerve block is infusing4 • Excessive sensory or motor blockade in the lower extremities may result in signs of pressure and skin breakdown on the heels 4 4. Monitor the infusion rate Ensures that medication is according to institutional policy. administered safely and securely. Ensure that the control panel is locked if using a volumetric infuser or ensure that the PCA program is locked via a key or code access. Disposable infusion devices (e.g., elastomeric pumps) have been shown to be less accurate than volumetric pumps.30,35 5. Monitor oxygen saturation and Assesses ventilation and oxygenation. • Oxygen saturation < 93% or capnography (if available) decreasing trend in oxygenation continuously, especially if parenteral opioids are administered for pain or mild sedation before, during, or after the procedure.4,11 6. Assess temperature regularly; Increasing hyperpyrexia could signify • Temperature > 101.3 °F (38.5 °C) assess more frequently if febrile. infection. 12 7. Assess the catheter site every 4–8 Identifi es site complications. • A change in the integrity of the hours and as needed. peripheral nerve block insertion site (e.g., redness, tenderness, or swelling or the presence of exudate on the dressing) Procedure continues on following page 956 Unit III Neurologic System

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 8. Observe for signs and symptoms The catheter is no longer in the • Unexpected change in sedation of peripheral nerve catheter correct position. scale migration into a blood vessel. • Drowsiness • Dizziness • Blurred vision • Slurred speech • Poor balance • Circumoral numbness • Hypotension • Cardiovascular collapse 9. Monitor sensory or motor loss Motor or sensory loss may result • Unexpected change in sensory or according to the defi ned goal of from the local anesthetic infusion. motor function beyond the defi ned therapy. (Level D * ) Note: With peripheral nerve goal of therapy blockade, sensory loss is usually • Interference with respiration or acceptable and often desirable. excessive spread of local anesthetic Motor loss is not desirable but beyond the defi ned area of often acceptable.3,5,18,23,39 recommendation 10. Assess for systemic toxicity from Local anesthetic is used in the • Metallic taste the local anesthetic administered solution, and symptoms indicative • Blurred vision through the catheter. of systemic toxicity from the agent • Circumoral numbness used to induce anesthesia may • Tinnitus occur. • Decreased hearing • Dizziness • Confusion progressing to seizures 11. Monitor and check the skin If a local anesthetic is used in the • Increasing redness or blistering of integrity of the pressure points solution, check for pressure the skin on pressure points relating to the location of the ulceration (patient may have peripheral nerve block (e.g., sensory loss in areas adjacent to the elbow, sacrum, and heels). area of the peripheral nerve Change patient’ s position as block).3,23 needed. Provide protective positioning. 3,23 12. Change the peripheral nerve Provides an opportunity to cleanse the • Signs of site infection (e.g., block catheter insertion site area around the catheter and to swelling, pain, redness, or presence dressing as prescribed or if assess for signs and symptoms of of drainage) soiled, wet, or loose. 7 Note: infection. 12,23 • Leakage of the peripheral nerve Usually the dressing is left intact block solution for the duration of therapy unless wet or loose. 6 13. Label the peripheral nerve block Aids in minimizing the risk for pump and consider placing the mistaking the local anesthetic pump on one side of the patient’ s infusion for an IV infusion system.7 bed and all other pumps on the other side of the bed. 6

* Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations. 107 Peripheral Nerve Blocks: Assisting with Insertion and Pain Management 957

Documentation Documentation should include the following: • Patient and family education • Regional analgesic medication and the medication • Patient tolerance of procedure concentration being infused and infusion rate; • Completion of informed consent remaining volume of medication in a disposable • Completion of a preprocedure verifi cation and time out infusion device • Catheter location • Bolus dose administration (if appropriate) and patient • Type of dressing used response after a bolus dose, including quality of pain • Confi rmation of peripheral nerve block catheter relief placement (e.g., radiological confi rmation, stimulating • Vital signs and oxygenation saturation. peripheral nerve catheter, ultrasound scan) • Occurrence of unexpected outcomes • Site assessment • Nursing interventions taken • Assessment of pain and levels of motor and sensory • Date and time of discontinuation of treatment blockade documented on an appropriate fl ow chart (see • Pain assessment, interventions, and effectiveness Fig. 107-3 ). • If PCA is used, document medication concentration, PCA bolus dose, continuous infusion, lockout interval, hourly limits, and total dosage

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .