A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
a. Redness at the catheter insertion site
b. Report of headache and stiff neck
c. Temperature of 100.1 ° F (37.8 ° C)
d. Pain rating of 8 on a scale of 0 to 10
ANS: B
Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101 ° F are signs of meningitis and should be reported to the provider immediately. The other findings are important but do not require immediate intervention.
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