week 2 dq 1

1578185 - Elsevier Health Sciences ©

P R O C E D U R E 1 0 7

Peripheral Nerve Blocks

Assisting with Insertion and Pain Management

Kimberly Williams

P U R P O S E :

Peripheral nerve blocks are administered as single local anesthetic injections or continuously through a catheter placed into a precise anatomical area to provide site-specific analgesia or anesthesia.

Prerequisite Nursing Knowledge • State boards of nursing may have detailed guidelines involving peripheral nerve blockade. Each institution that

provides this therapy also has policies and guidelines pertaining to peripheral nerve blockade. It is important that the nurse is aware of state guidelines and institutional policies.15

• The nurse must have an understanding of the principles of aseptic technique.9,12,19,23,39

• The nurse assisting with the insertion of peripheral nerve blocks requires specific skills and knowledge.15

• Catheter placement and management of the patient should be under the direct supervision of an anesthesiologist, nurse anesthetist, or the acute pain service.24,26,39 Peripheral nerve blocks are used as part of a preemptive and multimodal analgesic technique to provide safe and effective postoperative pain management with minimal side effects.10,12,14,18,21

• Peripheral nerve blocks are site specific (e.g., femoral, brachial plexus, axillary, intrapleural, extrapleural, paravertebral, tibial, sciatic, lumbar plexus) and provide prolonged anesthesia or analgesia for postoperative and trauma pain management.4,26

• Peripheral nerve blocks in the outpatient setting have facilitated early patient ambulation and discharge by decreasing side effects, such as drowsiness, nausea, and vomiting.3,11,13,18 In addition, unlike general anesthesia, peripheral nerve blocks do not directly alter the level of consciousness. By preserving the patient's level of consciousness, the patient's protective airway reflexes (e.g., cough and gag) are maintained and the need for airway manipulation and intubation is negated. Furthermore, with the use of peripheral nerve blockade, the complications of general anesthesia are avoided.3 Continuous peripheral nerve blockade improves postoperative analgesia, patient satisfaction, and rehabilitation compared with intravenous (IV) opioids for upper- and lower-extremity procedures.11,13,18,26,31

• The anatomical position of the specific catheter should be clearly defined and documented after insertion by the physician or advanced practice nurse (e.g., femoral, axillary [Figs. 107-1 and 107-2], brachial plexus [Fig. 107-3], intrapleural, extrapleural, paravertebral, tibial, sciatic, lumbar plexus).5,32 Radiological confirmation6 of the catheter position may be necessary to avoid suboptimal outcomes (e.g., pneumothorax). Catheters may be placed by the surgeon, anesthesiologist, or certified nurse anesthetist under direct vision, via ultrasound scan– guided techniques or with the use of a peripheral nerve stimulator, either adjacent to or directly into the nerve

1578185 - Elsevier Health Sciences ©

sheath (e.g., sciatic or tibial nerve during surgery for lower-limb amputation).16,19,21,23,29,31 Catheters may also be placed after surgery (e.g., intercostal, intrapleural, axillary, brachial plexus, femoral, paravertebral; Table 107-1).

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

1578185 - Elsevier Health Sciences ©

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

1578185 - Elsevier Health Sciences ©

FIGURE 107-3 Landmarks for interscalene brachial plexus block. (From Sinatra RS: Acute pain: Mechanisms & management, St Louis, 1992, Mosby.)

1578185 - Elsevier Health Sciences ©

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 fracture)

• Horner's syndrome may obscure neurological assessment

• Block of ipsilateral phrenic nerve

• Close proximity to tracheostomy and jugular vein line sites

Cervical paravertebral (continuous catheter only)

Shoulder/elbow/wrist pain (e.g., shoulder fractures, humeral fracture, elbow fractures, wrist fractures)

• Horner's syndrome may obscure neurological assessment

• Block of ipsilateral phrenic nerve

• 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 fractures. Commonly an elastomeric infusion pump, which is a balloon filled 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.

• Catheter malposition

• Risk of pneumothorax

Paravertebral Unilateral chest or abdominal pain restricted to a few dermatomes (e.g., rib fractures)

• Patient positioning

• Stimulation success sometimes hard to visualize

Combination of femoral and

Unilateral leg pain (e.g., femoral neck fracture [femoral], tibial and ankle fractures [sciatic])*

• Patient positioning

1578185 - Elsevier Health Sciences ©

sciatic block • Interference of femoral nerve catheters with femoral lines

*Caution: Compartment syndrome. Modified from Schulz-Stubner S: The critically ill patient and regional anesthesia, Curr Opin Anaesthesiol 19:538–544, 2006.

• A three-in-one peripheral nerve block can be used for analgesia after proximal lower-limb orthopedic surgery. A three-in-one peripheral nerve block provides analgesia to block three nerves, including the lateral femoral cutaneous, femoral, and obturator nerves.4,26 This block is as effective as epidural analgesia, with fewer side effects than epidural analgesia (e.g., urinary retention, nausea, risk for epidural hemorrhage in patients with anticoagulation).6,7,16,26,27 Some forms of plexus analgesia (e.g., brachial plexus analgesia) in the postoperative setting may serve two purposes: pain relief and sympathetic blockade, the latter of which increases blood flow and may improve outcomes in some cases (i.e., digit reimplantation).5,16,23,34

• Analgesia via a catheter may be administered as a continuous infusion with the use of a volumetric pump system, a patient-controlled regional infusion system, or a disposable pump device (e.g., elastomeric). An elastomeric pump is one type of disposable infusion pump designed to provide a constant rate of infusion from a filled reservoir. The infusion rates may or may not be adjustable (Fig. 107-4).21,30,34 Medication administered is usually a local anesthetic (e.g., bupivacaine, ropivacaine). Other agents have been used on an adjunctive basis as a bolus, including opioids, clonidine, epinephrine,16,17 and neostigmine.18

FIGURE 107-4 An elastomeric infusion pump. Parts include 1, filling port; 2, elastomeric balloon (drug-containing reservoir); and 3, outer protective shell. (Originally published in Skryabina E, Dunn TS: Disposable infusion pumps, Am J Health Syst Pharm 63:1260-1268, 2006.) © 2006, American Society of Health-System Pharmacists, Inc. All rights reserved. Reprinted with permission (R1002).

• The pharmacokinetics and pharmacodynamics of local anesthetics and other agents used, including side effects and duration of action, should be clearly understood. Local anesthetic medications used for peripheral nerve blocks provide surgical analgesia (i.e., loss of pain sensation) and anesthesia (i.e., loss of all sensation). The duration of action for each anesthetic medication depends on several factors, including the volume injected, concentration of the medication, site of injection, and absorption. The addition of a vasoconstrictor, such as epinephrine, constricts blood vessels and reduces vascular uptake, which further prolongs the duration of action of the local anesthetic.16,17 Epinephrine is not recommended with peripheral nerve blocks in areas with end arteries, such as ear lobes, the nose, digits, and the penis.39 Vasoconstrictor medications may cause spasm of blood vessels, resulting in necrosis.9 Knowledge of signs and symptoms of profound motor and sensory blockade, or overmedication, is essential.5,9,10,17

1578185 - Elsevier Health Sciences ©

• Sensory and motor blockade may be acceptable or desirable, depending on the goals and preferences of the interdisciplinary team. The loss of sensation at the site is often the primary goal of blocks, and although motor loss is often acceptable, it is not desirable.3

• Relative contraindications to peripheral nerve blockade include a history of coagulopathy, preexisting neuropathies, anatomical or pathological deviations at the injection site, and systemic disease or infection.5,7,10,22,26,27,39

• Local anesthetic toxicity can result from inadvertent injection of local anesthetic into the vascular system or rapid absorption of the agent from the tissue into the vascular system. Intralipids/20% fat emulsion should be immediately available for IV infusion, to help restore cardiovascular stability.8

Equipment • One peripheral nerve catheter kit • Infusion set for continuous plexus anesthesia with or without an adaptor for a nerve stimulator • Peripheral nerve stimulator • Topical skin antiseptic, as prescribed • Sterile towels • Sterile forceps • Sterile gauze 4 × 4 pads • Sterile gloves and gowns • Fluid shield face masks • 20-mL normal saline solution • 5- to 10-mL local anesthetic as prescribed (1% lidocaine) for local infiltration • Local anesthetic as prescribed (to establish the block) • Occlusive dressing supplies to cover the catheter entry site • Gauze and tape to secure the catheter to the patient's body • Labels stating “Local anesthetic only” and “Not for intravenous injection” • 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

• Specific observation chart for patient monitoring of the peripheral nerve block infusion • Prescribed analgesics and local anesthetics • Equipment for monitoring blood pressure, heart rate, and pulse oximetry

Additional equipment, to have available as needed, includes the following: • Ice or alcohol swabs for demonstrating sensory block • Emergency medications (e.g., 20% fat emulsion/intralipids for local anesthetic toxicity) • Bag-valve-mask device and oxygen • Equipment for end-tidal carbon dioxide monitoring • Intubation equipment • Peripheral nerve stimulator and/or ultrasound to facilitate placement

Patient and Family Education • Explain the reason and purpose of the catheter. If available, supply easy-to-read patient information. Rationale:

The patient and the family know what to expect; anxiety may be reduced. • Explain to the patient and family that the procedure can be uncomfortable but that a local anesthetic will be

used to facilitate comfort. Rationale: Explanation elicits the patient's cooperation and comfort, and facilitates insertion; anxiety and fear may be decreased.

• During therapy, instruct the patient to report side effects or changes in pain or sensation. Observe for suboptimal analgesia, profound numbness of extremities (beyond the goal of therapy), patient report of lightheadedness, metallic taste, circumoral numbness, dizziness, blurred vision, tinnitus, loss of hearing, and seizures.5,9,17,23 Rationale: Reporting of pain aids the patient's comfort level and identifies side effects.

1578185 - Elsevier Health Sciences ©

Recognition of early signs and symptoms of local anesthetic toxicity can prevent cardiac arrhythmias, arrest, and death.

• Teach the patient to protect the affected extremity from injury and trauma (e.g., burns).3,5,23 Rationale: Patient safety is increased, and the limb is protected from injury and trauma.

• If a volumetric pump for patient-controlled regional analgesia (PCA) is used, educate the patient and family on its use. Reinforce this education throughout the duration of regional PCA therapy. Rationale: This may decrease anxiety and assists the patient in effectively using the infusion system.

Patient Assessment and Preparation P a ti e nt Asse ssm e nt • Observe the patient for signs and symptoms of local infection or generalized sepsis. Rationale: This decreases

the risk for infection at the site of catheter insertion. Septicemia and bacteremia are contraindications for peripheral nerve block catheter placement or continuation of therapy.10,12

• Assess the patient's concurrent anticoagulant and fibrinolytic therapy.6,7,39 Rationale: Heparin (unfractionated and low–molecular-weight heparin), heparinoids, and fibrinolytic agents administered concurrently increase the risk for vessel trauma (e.g., hematoma). Care must be taken with insertion and removal of the peripheral nerve block catheter when patients are on anticoagulant and fibrinolytic therapy.9,27 Special institutional guidelines must be observed.3,5–7,19,25,27 Insertion and removal of the peripheral nerve catheter should be directed by the physician or advanced practice nurse.5–7,27

• Obtain the patient's vital signs. Rationale: This provides baseline data. • Assess the patient's pain and anxiety. Rationale: This provides baseline data and helps determine whether

premedication is required. • Reassure the patient. Rationale: Anxiety and fears may be reduced. • Review the patient's medication allergies. Rationale: Review of medication allergies before administration of a

new medication decreases allergic reactions. • Consider instructions for nothing by mouth, especially if sedation or general anesthesia is to be used. Rationale:

The risk for vomiting and aspiration is decreased.

Patient Preparation • Verify that the patient is the correct patient using two identifiers. Rationale: Before performing a procedure, the

nurse should ensure the correct identification of the patient for the intended intervention. • Ensure that the patient and family understand the planned procedure. Answer questions as they arise, and

reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.

• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and makes a competent decision possible for the patient.

• Perform a preprocedure verification and time out, if nonemergent. Rationale: This ensures patient safety. • Wash the specific anatomical area of the patient's body with soap and water, and open the gown to expose the

site for injection while maintaining the patient's privacy and dignity. Rationale: This action cleanses the skin and allows easy access to the specific anatomical area of the patient's body.

• Establish IV access or ensure the patency of IV catheters. Rationale: Medications may be needed if side effects occur (i.e., hypotension).

• Position the patient as appropriate, according to which anatomical area of the body is to be blocked. Rationale: This prepares the patient for the procedure.

Procedure for Peripheral Nerve Blocks

1578185 - Elsevier Health Sciences ©

Steps Rationale Special Considerations

1.

2. 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 nerve block medication.

The medication should be prepared with aseptic technique by the pharmacy with laminar flow or prepared commercially.

All peripheral nerve block solutions are preservative free to avoid neuronal injury.7

4. Connect the correct tubing to the prepared infusion and prime the tubing.

Removes air from the infusion system.

5. Ensure that the patient is in position for catheter placement.

Facilitates ease of insertion of the peripheral nerve block catheter.

Assist with holding the patient in position or consider sedation, if necessary.

6. Assist as needed with the antiseptic preparation of the intended insertion site. (Level C*)

Reduces the transmission of microorganisms into the nerve sheath or plexus space.12,23

The choice of povidone-iodine or chlorhexidine as an antiseptic agent for neurological procedures is controversial. Both should be allowed to dry completely. Chlorhexidine may be neurotoxic.20

7. Assist if needed with draping the patient with exposure of the insertion site.

Aids in maintaining sterility.

8. Assist the physician or advanced practice nurse as needed with the catheter placement and manipulation of the controls on the peripheral nerve stimulator if used).3,23 (Level C*)

Facilitates catheter insertion. Use of a peripheral nerve stimulator assists with identification of the nerve.23,28

Ultrasound guidance may be used to place the continuous peripheral nerve block catheter. If ultrasound has print capability, print a reading and include it in the chart for documentation.

9. After the peripheral nerve catheter is inserted, assist as needed with the application of a sterile, occlusive dressing.

Reduces the incidence of infection.12,23

10. Secure the filter to the patient's body with a gauze padding and tape.

Avoids disconnection between the peripheral nerve catheter and the filter. The gauze padding prevents discomfort and skin pressure from the filter.

11. The physician or Facilitates a therapeutic level of An initial test dose of local anesthetic agent

1578185 - Elsevier Health Sciences ©

advanced practice nurse will administer a bolus dose of medication via the catheter.

analgesia and ensures correct catheter placement.39

with or without epinephrine may be administered, then a bolus 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 medication infusion system.

Prepares the infusion system.

13. Initiate therapy:

A. Place the system in a volumetric pump or elastomeric continuous infusion pump and set the rate and volume to be infused as prescribed.

Prepares the infusion system. Responses to peripheral nerve block analgesia vary individually, and analgesia is tailored according to individual responses. Note: Peripheral nerve catheters may also 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 anesthetic only—Not for intravenous injection” to the tubing and use a portless system.5 (Level D*)

Do not give any other solution or medication via this catheter.

Inadvertent administration of some IV medications into the peripheral 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 volumetric pump.

Prevents inadvertent or accidental changes in therapy.

14. Continue to assess the quality of the analgesia.

Identifies patient comfort level and is an indicator to clinicians regarding the effectiveness of the therapy.

A. Determine the patient's pain based on a consistent and reliable pain- assessment tool according to institutional policy.33

The amount of pain experienced by the patient should be no more than the amount of what is acceptable to the patient.1,2,9

B. Assist as needed with testing the corresponding dermatome level of the peripheral nerve block with

The ideal peripheral nerve block should be just above and just below the (anticipated) surgical incision or the trauma site (see the dermatomes described in Fig. 107-3).9,23

1578185 - Elsevier Health Sciences ©

ice or an alcohol swab.

15. Remove and discard used supplies in an appropriate receptacle.

Removes and safely discards used supplies.

16. *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.

Expected Outcomes • Regional analgesic catheter inserted; accurate catheter placement confirmed with use of ultrasound scan,

nerve stimulator, or radiological imaging when appropriate5,6,18,22,29,31

• Pain minimized or relieved3,31,32

• No patient oversedation or respiratory depression5,17,39

• Reduced need for parenteral opioids, thereby also reducing opioid side effects18,23

• Potential for reduction in neuropathic pain states, especially after limb amputation14

• Temporary numbness and loss of motor control23

Unexpected Outcomes • Inability to insert the catheter • Untimely or erroneous medication administration5,9

• Suboptimal analgesia • Adverse medication reactions not recognized • Altered skin integrity from decreased sensory and motor loss6,9,16,37,38

• Accidental dislodgment of the catheter delivery system • Leakage from the catheter insertion site • Cracked filter on the delivery system • 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 stellate ganglion 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 • Sepsis12

• Anaphylaxis5,17

• Permanent neurological injuries and damage from insertion26,39

• Systemic toxicity from local anesthetics (e.g., tachycardia, hypotension, metallic taste, blurred vision, circumoral numbness, tinnitus, decreased hearing, dizziness, confusion progressing to seizures, cardiac arrest, or even death)5,17,23

Patient Monitoring and Care

1578185 - Elsevier Health Sciences ©

Steps Rationale Reportable Conditions

These conditions should be reported if they persist despite nursing interventions.

1. Assess the patient's level of pain with a valid and reliable pain scale. Follow institutional standards for assessing pain. Administer analgesia as prescribed. Continue to assess frequently, especially during the first 12–24 hours of therapy.2,9,23,33

Identifies the need for pain interventions. Describes the patient's response to pain therapy. A lower pain score is expected. Assessing and reassessing pain in an objective manner helps determine appropriate treatment measures.

• Continued pain despite pain interventions

2. Assess the patient's vital signs, oxygenation and ventilatory status, and level of sedation with a valid and reliable sedation scale.15,33 Monitoring the patient every 15 minutes has been recommended in the immediate period after initiation of therapy.23

Hypotension and sedation may reflect IV infusion, systemic toxicity, or the residual effects of sedation administered for catheter placement.21,23

• Change in respiratory status or other vital signs (e.g., respiratory rate, oxygenation via pulse oximetry, blood pressure)

• Altered level of consciousness

3. Assess the levels of motor and sensory blockade. Follow institutional standards for these assessments (see Fig. 107-3).1–3,9,23

Ensures effectiveness of analgesia and maintenance of the block at the correct level.

• Signs and symptoms of overmedication: • Decreased

ability to feel or to move area of the body where 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 heels4

4. Monitor the infusion rate according to institutional policy. 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

Ensures that medication is administered safely and securely.

5. Monitor oxygen saturation and capnography (if available) continuously, especially if parenteral opioids are

Assesses ventilation and oxygenation.

• Oxygen saturation <93% or

1578185 - Elsevier Health Sciences ©

administered for pain or mild sedation before, during, or after the procedure.4,11

decreasing trend in oxygenation

6. Assess temperature regularly; assess more frequently if febrile.

Increasing hyperpyrexia could signify infection.12

• Temperature >101.3 °F (38.5  °C)

7. Assess the catheter site every 4–8 hours and as needed.

Identifies site complications. • A change in the integrity of the peripheral nerve block insertion site (e.g., redness, tenderness, or swelling or the presence of exudate on the dressing)

8. Observe for signs and symptoms of peripheral nerve catheter migration into a blood vessel.

The catheter is no longer in the correct position.

• Unexpected change in sedation scale

• Drowsiness • Dizziness • Blurred vision • Slurred speech • Poor balance • Circumoral

numbness • Hypotension • Cardiovascular

collapse

9. Monitor sensory or motor loss according to the defined goal of therapy. (Level D*)

Motor or sensory loss may result from the local anesthetic infusion. Note: With peripheral nerve blockade, sensory loss is usually acceptable and often desirable. Motor loss is not desirable but often acceptable.3,5,18,23,39

• Unexpected change in sensory or motor function beyond the defined goal of therapy

• Interference with respiration or excessive spread of local anesthetic beyond the defined area of recommendation

10. Assess for systemic toxicity from the local anesthetic administered through the catheter.

Local anesthetic is used in the solution, and symptoms indicative of systemic toxicity from the agent used to induce anesthesia may occur.

• Metallic taste • Blurred vision • Circumoral

numbness • Tinnitus • Decreased

hearing • Dizziness • Confusion

progressing to seizures

11. Monitor and check the skin integrity of the pressure points relating to the location of the peripheral nerve block (e.g., elbow,

If a local anesthetic is used in the solution, check for pressure ulceration (patient may have

• Increasing redness or blistering of the

1578185 - Elsevier Health Sciences ©

sacrum, and heels). Change patient's position as needed. Provide protective positioning.3,23

sensory loss in areas adjacent to the area of the peripheral nerve block).3,23

skin on pressure points

12. Change the peripheral nerve block catheter insertion site dressing as prescribed or if soiled, wet, or loose.7 Note: Usually the dressing is left intact for the duration of therapy unless wet or loose.6

Provides an opportunity to cleanse the area around the catheter and to assess for signs and symptoms of infection.12,23

• Signs of site infection (e.g., swelling, pain, redness, or presence of drainage)

• Leakage of the peripheral nerve block solution

13. Label the peripheral nerve block pump and consider placing the pump on one side of the patient's bed and all other pumps on the other side of the bed.6

Aids in minimizing the risk for mistaking the local anesthetic infusion for an IV infusion system.7

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

Documentation Documentation should include the following: • Patient and family education • Patient tolerance of procedure • Completion of informed consent • Completion of a preprocedure verification and time out • Catheter location • Type of dressing used • Confirmation of peripheral nerve block catheter placement (e.g., radiological confirmation, stimulating peripheral

nerve catheter, ultrasound scan) • Site assessment • Assessment of pain and levels of motor and sensory blockade documented on an appropriate flow chart (see

Fig. 107-3). • If PCA is used, document medication concentration, PCA bolus dose, continuous infusion, lockout interval,

hourly limits, and total dosage • Regional analgesic medication and the medication concentration being infused and infusion rate; remaining

volume of medication in a disposable infusion device • Bolus dose administration (if appropriate) and patient response after a bolus dose, including quality of pain

relief • Vital signs and oxygenation saturation. • Occurrence of unexpected outcomes • Nursing interventions taken • Date and time of discontinuation of treatment • Pain assessment, interventions, and effectiveness