The nurse is assessing a patient receiving epidural analgesia after a total knee replacement. Which of the following is the priority assessment?


• Epidural catheter displacement can cause spinal injury and is a serious complication. Loss of sensation or movement in the legs is a sign of catheter displacement. Motor and sensory function should be assessed every 4 hours, prior to first ambulation, and again 4 hours after the catheter is discontinued.

• The epidural insertion site assessment should be performed every 4 hours (not Q 12 hours) and prior to bolus administration and until 12 hours after the catheter has been removed.  Assess for displacement, leakage, kinking, redness, fluid or bleeding, or hematoma.  The dressing is changed daily.

• Assessing peripheral pulses is part of the routine nursing assessment, but it is not the highest priority.

• The patient does not need to be on flat bed rest and may ambulate. This is also not an assessment.

Visit our website for other NCLEX topics now!