Peripheral Nerve Blocks: Understanding the Nurse’s Role

CONTINUING EDUCATION

Peripheral Nerve Blocks: Understanding theNurse’s Role

Karen L. McCamant, MSN, RN, CAPA

This article describes the nursing care and management of patientsduring and after administration of peripheral nerve blocks. Wereview recommendations for patient monitoring, as well as the risksand complications associated with anesthetic agents. Several upperand lower extremity blocks, including the Bier block, are described.The nursing role in the use of the peripheral nerve stimulator is alsoexplained. Throughout the discussion, nursing responsibilities areemphasized.

© 2006 by American Society of PeriAnesthesia Nurses.

Objectives —After reading this article, the perianesthesia nurse should be able to (1) identifycommon peripheral nerve blocks used in surgery centers, (2) describe the physiology associated withperipheral nerve blocks, and (3) recognize and manage common complications associated with
peripheral nerve blocks.
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OVER THE PAST two decades, ambulatory sur-gery centers have proliferated as a result oftechnological advances that include the use ofperipheral nerve blocks for intra- and postoper-ative analgesia. Because the benefits of anes-thetic blocks include reduced levels of postop-erative pain, patients are able to ambulateearlier, thus decreasing the detrimental effectsof prolonged immobility, such as pneumoniaand deep vein thrombosis. Similarly, patientswho have received peripheral nerve blocks re-

Karen L. McCamant, MSN, RN, CAPA, is a clinical instruc-tor for University of Delaware, Wilmington, DE, and formerStaff Nurse, Limestone Ambulatory Surgery Center, Wilming-ton, DE.

Address correspondence to Karen L. McCamant, BA, BSN,RN, CAPA, 394 Walnut Lane, North East, Maryland 21901;e-mail address: [email protected].

© 2006 by American Society of PeriAnesthesia Nurses.1089-9472/06/2101-0005$32.00/0

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uire less opioid analgesia during the recoveryeriod, reducing such uncomfortable side ef-

ects as constipation and excessive somno-ence.1 Also, once a block has been adminis-ered, minimal sedation is required duringurgery, and the overall risks associated withnesthesia are reduced. Intraoperatively, pro-ective airway reflexes are preserved in blockedatients when deep sedation or anesthesia isvoided. Some patients may opt for peripheralerve blocks to remain awake and observe theirurgical procedures, or minimize adverse ef-ects such as postoperative nausea, vomiting,nd drowsiness.

verall, patients who receive peripheral nervelocks do very well and report high levels ofatisfaction with their surgical experiences.1

he purpose of this article is to increase under-tanding of the principles behind peripheral
erve blocks while emphasizing the nursing
urnal of PeriAnesthesia Nursing, Vol 21, No 1 (February), 2006: pp 16-26

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PERIPHERAL NERVE BLOCKS 17

role in assisting with administration of the anes-thetic agents. The management of the patientduring the perianesthesia phases of care willalso be addressed.

Preliminary Considerations

For ambulatory surgery centers, the successfulincorporation of peripheral nerve blocks intothe routine necessitates certain considerations.For example, anesthesia providers proficient inthe administration of regional anesthesia, in-cluding anesthesiologists and certified regis-tered nurse anesthetists, must be available toadminister the blocks, as well as to monitor andmanage the care of the patient. For many anes-thesia providers, techniques for administeringnerve blocks are learned only after they enterpractice. Specifically, in a survey to determinethe extent and availability of training in periph-eral nerve block techniques, Chelly et al foundthat only 58% of American anesthesiology resi-dency program directors reported offering aperipheral nerve block rotation.2 In addition,careful scheduling coordination between thecenter and the surgeon is needed to ensureadequate time before the start of surgery (“setup”) “for the block to be administered andbecome effective.”1

Although provider issues are clearly important,certain patient issues must also be considered,and thorough preanesthesia screening must oc-cur to determine which patients are appro-priate candidates for peripheral nerve blocks.Table 1 provides a list of potential contraindica-

Table 1. Possible Contraindica

● Pre-existing coagulopathies, either endogenous (eg,to increased risk of hematoma1

● Anatomic anomalies that make identification of phys● Pre-existing neuropathies, which might cause the blo● Hepatic disease that may interfere with clearance3

● Excessive preoperative anxiety (not responsive to int● Inability to tolerate positioning● Known allergies to local anesthetic agents3,5

tions for peripheral nerve blocks. t

ypes Of Peripheral Nerve Blocks

here are several types of regional anesthesiaurrently used in surgery centers, including ax-llary, femoral, and popliteal peripheral nervelocks. With these blocks, the anesthesia pro-ider injects the local anesthetic into the tissueurrounding the nerve, proximally to the oper-tive site, with the patient mildly sedated. Nee-le placement is determined initially by usingnatomic landmarks. Next, a peripheral nervetimulator is used to facilitate precise location ofhe appropriate nerve. The anesthetic effectccurs primarily distal to the injection sites. Forxample, a popliteal block may be used foristal surgical procedures, such as the Achillesendon repair. In contrast, intravenous (Bier)erve blocks are administered distal to the sur-ical site and rely on diffusion rather than directnjection to achieve anesthetic effects. Blocksre typically administered in the preoperativerea. The various types of peripheral nervelocks are presented in the Table 2.

nderstanding The Physiology

ll local anesthetic agents used in peripheralerve blocks induce physiologic responses viahe same mechanism. Specifically, anestheticsnterfere with the neuronal membrane’s perme-bility to sodium. Disruption of sodium ex-hange results in inhibition of neuronal im-ulses between the affected extremity and therain. Consequently, sensory, motor, and sym-athetic neural pathways are affected, and theatient is unable to feel or move the anesthe-

for Peripheral Nerve Blocks

bocytopenia) or iatrogenic (eg, warfarin therapy) due

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KAREN L. McCAMANT18

peripheral vasodilation and erythema due tounopposed parasympathetic activity, causing ar-teriolar vasodilation.3

Adverse effects of local anesthetics typicallyoccur as a result of high blood levels of thedrugs, and they are similar among all agents inuse. Signs of systemic toxicity include tinnitus,sudden metallic taste, confusion that progressesrapidly to loss of consciousness, seizures, andabrupt onset of cardiac dysrhythmias.1 Neuro-logic symptoms are likely to appear before car-diovascular disturbances, unless epinephrinehas been added to the block.4,5 Inadvertentsystemic administration of anesthetic combina-tions containing epinephrine will cause tran-sient tachycardia and hypertension.1,4 Hyper-sensitivity, or allergic reactions, although rare,are also a concern with regional anestheticagents, and are more likely to occur with ester-based agents than with amides.5 Esters includeprocaine, chloroprocaine, tetracaine, and piper-ocaine, whereas amides include bupivacaine,mepivacaine, and prilocaine.5 Signs of hyper-

Table 2. Examples of Peripheral Nerve BlocksWith Representative Surgical Procedures

Upper Extremity BlocksExamples of Surgical

Procedures

Interscalene brachialplexus block

Closed shouldermanipulation

Intraclavicular brachialplexus block

Synovectomy ofrheumatoid elbow

Axillary brachial plexusblock

Olecranon bursectomy

Bier block (for surgeriesof the hand and wrist)

Release of deQuervain’stenosynovitis orDupuytren’scontracture

Lower ExtremityBlocks

Sciatic nerve block Excision of Baker’s cystFemoral nerve block Reduction of leg fracturesPopliteal nerve block Achilles’ tendon repairIntra-articular knee Arthroscopic meniscectomy

ablock

ensitivity reaction include rash, erythema, itch-ng, hives, and edema, and may progress toronchospasm, hypotension, vascular collapse,nd anaphylactic shock.3,5 Table 3 lists possibledverse effects associated with regional anes-hetic agents, differentiating between allergiceactions and toxicities.

eural blockade may last from 2 to 24 hours,ith duration of anesthetic effect based on the

pecific anesthetic agent used and site of injec-ion. In general, motor ability returns beforeensation, and sympathetic resolution occursast.1 The nursing implications of this progres-ion are clear, because patients are able to moveheir limbs before they can feel them, leading to

high risk for injury. In addition, prolongedympathetic blockade can lead to increased riskf postoperative swelling. Ice and elevation areelpful until sympathetic function normalizes.are of the anesthetized limb represents a keyursing responsibility, but nurses must also pro-ide adequate teaching, so that the patient canrotect the limb after discharge.

ursing Responsibilities

articipation in the administration of peripheralerve blocks may vary according to state boardules and regulation. The nurse may be asked to

Table 3. Possible Adverse Reactions AssociatedWith Regional Anesthetic Agents

Toxicities1,3,6 Allergic Reactions3–5

Dysrhythmias,including cardiacarrestConfusion progressingrapidly to seizuresNausea, vomiting,diarrheaSensory disturbances� Blurred vision� Tinnitus� Metallic tastePermanent neurologic injury

● Urticaria● Gastrointestinal

upset● Conjunctivitis● Laryngeal edema● Angioedema● Respiratory

distress/arrest● Precipitous

hypotension● Anaphylaxis

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stimulator and to operate the syringe that con-nects to the needle via extension tubing. Thenurse may also monitor patient status in con-junction with the anesthesia provider.

In most states, RNs, with the exception ofCRNAs, may not perform peripheral nerveblocks by themselves, nor may they fulfill anyfunction other than that of first assistant. Specif-ically, RNs are usually not permitted to insert ormanipulate the needle that is connected to theperipheral nerve stimulator, nor directly injectthe anesthetic agent into the nerve plexus. Be-cause of variations in regulations, nurses shouldalso check with their state boards of nursingbefore administering anesthetic agents such aspropofol or ketamine to sedate patients duringthe administration of nerve blocks. Similarly,nurses should also follow institutional policiesregarding the delivery of conscious/moderatesedation.

When caring for patients receiving peripheralnerve blocks, the nurse’s responsibilities in-clude evaluating the overall patient status usingcontinuous electrocardiogram (ECG) monitor-ing and pulse oximetry. Nurses must be able torecognize the signs and symptoms of systemictoxicity as described in Table 3. In addition,nurses should be prepared to initiate advancedcardiac life support protocols as indicated, withthe awareness that anesthetic agents may causesymptoms such as myocardial depression orrespiratory arrest that are refractory to pharma-cologic treatment. Because local anesthetics arerelatively short acting when administered sys-temically, long-term sequellae are rare if provid-ers respond quickly. And as with all medica-tions, nurses should also remain vigilant forsigns of allergic reaction, which include urti-caria, rapid onset gastrointestinal upset, con-junctivitis, angioedema, laryngeal edema, andhypotension.3,5 Symptoms should be treatedwith diphenhydramine, H2 inhibitors (famoti-dine, ranitidine), steroids, and adjunct airway
management as needed. O
lthough documentation policies vary bynstitution, nurses are responsible for not-ng admission information and baseline vitaligns, as well as the patient’s general toler-nce of the peripheral nerve block proce-ure during the preoperative period. It haseen suggested that nurses document vitaligns every 15 minutes during the first hourfter the block is administered until theatient is taken to surgery.1 In addition,urses should note the degree of anestheticffect, and report problems to the anesthe-ia provider before the patient is transferredo the operating room. Documentationbout the type and quantity of the anes-hetic agents used, as well as anestheticrocedure notes, is the responsibility of thenesthesiologist or the nurse anesthetistho administered the block.

he Peripheral Nerve Stimulator

s previously mentioned, initial needle inser-ion is guided by the topography of anatomicalandmarks. The peripheral nerve stimulator maye used to precisely locate the nerve to injecthe local anesthetic as close as possible to it.he stimulator consists of an insulated conduct-

ng needle attached to both the electrical unitnd a syringe containing anesthetic agents. Theatient is usually lightly sedated, but still some-hat interactive, when the nerve stimulation is

nitiated. This allows the procedure to be toler-ted comfortably, while the patient remainsble to offer feedback to facilitate accuratelacement of the anesthetic.

sing topographical cues, the anesthesia pro-ider inserts the needle with the initial electricalmplitude usually set at 1.5 to 2.0 mA. If ap-roved by the state’s Board of Nursing, theurse may be asked to assist by regulating themplitude of electrical impulse being adminis-ered and/or injecting the anesthetic under theirection of the anesthesia provider. When theip of the insulated needle approaches theerve, a gross motor response is observed.
nce the twitching begins, the nurse will

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KAREN L. McCAMANT20

slowly decrease the amplitude, calling the val-ues as they drop. Meanwhile, the providerslowly moves the needle closer to the nervewithout actually touching it. A quiet motor re-sponse that remains visible at 0.5 mA or lowerindicates that optimal proximity to the nervehas been achieved.

Once the needle has been correctly placed, thenurse will initiate injection of 20 to 50 mL ofanesthetic agent into the interstitium per theanesthesia provider’s instructions. The nursemust first aspirate for blood return to ensurethat a vessel has not been inadvertently cannu-lated. Aspiration is then repeated after every 5mL of anesthetic is given to continually verifythat the needle has not migrated into the vascu-lature. The nurse can expect to feel consider-able resistance on the syringe plunger if the tipof the needle is near the nerve. Abrupt loss ofresistance may indicate that the needle tip hasmoved, and placement must be immediatelyrechecked by aspiration. During injection, thenerve stimulator may be turned off at the dis-cretion of the anesthesia provider. The comple-tion of one block may require several needleinsertions, with the nerve stimulator reset eachtime. Although the anesthesia provider admin-istering the block determines when administra-tion is complete, loss of motor function indi-cates that the procedure has been successful.6

Nursing Considerations for SpecificBlocks

While all patients receiving peripheral nerveblocks should be fully monitored for complica-tions with continuous ECG and pulse oximetry,nurses should also be knowledgeable of site-specific considerations. For example, blocks in-volving the interscalene and infraclavicular ap-proaches to the brachial plexus carry thehighest risk of serious complications including arisk of tension pneumothorax.5 For patientsreceiving these particular blocks, nurses needto monitor for dyspnea or absent breath soundson the affected side. Other complications of
blocks involving the brachial plexus include w
psilateral phrenic nerve paralysis and Horner’syndrome. These symptoms may not requirereatment unless the patient becomes overlynxious.6 Nursing considerations for patientseceiving interscalene blocks are summarized inable 4.

ike the interscalene block, the axillary blockan be used for upper extremity surgery. Al-hough this block also involves the brachiallexus, this alternative approach presents virtu-lly no risk of tension pneumothorax, and doesot result in phrenic paralysis. Nurses assistingith an axillary block need to remain attentive

o the position of the arm, which is raised overhe patient’s head. Care must also be taken tovoid excessive abduction of the limb. Finally,n all upper extremity blocks, the absence ofensory and motor function both during andfter the procedure can lead to high risk fornjury; therefore, protecting the anesthetizedimb represents a key nursing responsibility.

lower extremity block that is becoming in-reasingly popular in surgery centers is the in-ra-articular knee block, which is used for ar-hroscopic surgery, such as meniscectomy. Thenesthesia provider injects the medication di-ectly into the synovial capsule, making use ofhe electrical nerve stimulator unnecessary. Sen-ation and motor response remain intact abovend below the knee, but patient comfort isttained such that little or no further sedationay be required to complete the surgery. With

pproval of the surgeon, many patients evenbserve the images on the screen along withhe surgical team.

he Intravenous Regional or Bierlock

lthough the anesthetic agents used in Bierlocks are not administered in the preoperativeettings, perianesthesia nurses should have annderstanding of the underlying principles in-olved in intravenous regional anesthesia. Theldest peripheral nerve block, the Bier block,
as first described in 1908 by German physi-

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cian August Bier and is used today for upperextremity procedures including hand surgery,closed reduction of fractures, and even postfrac-ture pain relief in the emergency department.7

The intravenous regional block can be used onlower extremities, but it is more commonlyadministered in upper extremities. The Bierblock is based on the principle of diffusionthrough semipermeable capillary membranes,and its effectiveness relies heavily on adequatelimb exsanguination and tourniquet applicationin the operating room.8 Specifically, hydrostaticpressure causes the anesthetic agent to diffusefrom the bloodless capillaries into the surround-ing tissues.9

For the Bier block, one IV line is inserted on thenonoperative limb to administer fluids and se-dation, and a second intravenous IV cannula is

Table 4. Nursing Considerations fo

● Position patient supine with head turned away from● Consider alternatives for patients with history of sev

� Ipsilateral phrenic paralysis is an expected physiolasymptomatic in general. The most common symptshould:� Remain with the patient; provide reassurance� Place patient in semi-Fowler’s position, or posi� Continue supplemental O2

● Monitor for Horner’s syndrome. This syndrome resulresponse that includes:� Ipsilateral pupillary constriction� Conjunctival hyperemia� Nasal congestion� Hoarseness

● Monitor for suspected tension pneumothorax (rare)1

� Continue supplemental O2

� Immediate chest radiograph� Upright anterior-posterior and lateral is optima� Cross-table decubitus with suspected side up i

� Remain vigilant for signs of hemodynamic decomp� Hypotension, tachycardia

� Prepare for insertion of chest tube� Arrange transfer as appropriate (15–20% of patien

hospitalization, but may be monitored in a short-s

placed preoperatively in the affected arm, distal l

o the surgical site. In the operating room, therm is lifted and a compression bandage appliedo promote exsanguination. Then tourniquetsre applied and inflated, and they remain in-ated throughout the procedure. An anesthesi-logist or nurse anesthetist then injects the localnesthetic medication into the surgical site IVine. The drug fills the occluded vessels andlowly diffuses through semipermeable capil-ary membranes and into surrounding tissue,ubsequently bathing the nerves and disruptingeuronal sodium exchange, resulting in loss ofensory and motor function.9

he primary complications of the Bier block areourniquet related and include compartmentyndrome, vascular reperfusion problems, anderve damage. Systemic bolus of the anestheticgent is an immediate risk if the tourniquet

ients Receiving Interscalene Blocks

tive site, operative arm and shoulder exposedspiratory diseasefect that occurs in all patients, and healthy patients areated to ipsilateral phrenic paralysis is anxiety. The nurse

f optimal comfort

sympathetic blockade and is an expected physiologic

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than 20 minutes after administration. Observa-tion in PACU Level I is generally not indicatedafter surgery with a Bier block, but it may occurat the discretion of the anesthesia provider. Anadditional drawback of this block is lack ofpostoperative analgesia, therefore oral painmedication may be indicated for the patientbefore discharge.8

Personal Protective Equipment

As always, nurses should exercise standard pre-cautions when assisting with nerve blocks. Inaddition, anecdotal evidence has emerged indi-cating that nurses are at risk for exposure withcontaminated injectate to mucus membranes(eg, mouth, eyes) if the needle inadvertentlyexits the patient’s skin while the anesthesiaprovider is injecting. Therefore, nurses assistingwith peripheral nerve blocks should considerwearing face shields for maximum protection.

Discharge Instructions

The provision of clear and complete dischargeinstructions remains a primary nursing respon-sibility. Readiness for discharge should be as-

Table 5. Discharge Instructions for P

Written and verbal discharge instructions should includ● Strategies for avoiding injury to the affected limb

� Use of sling until sensory and motor function re� Increased vigilance during movement� Cautionary information for smokers about cigare

● Duration of the anesthetic effect� Highly variable depending on the agents and typ

● Expected sensations that accompany recovery� Tingling, burning, paresthesia� Disruption in proprioception� Return of postsurgical pain

● Pain management once home� When to take pain medications� Dosing pain medications: around the clock sche

the discretion of the surgeon● When to call center or physician

� Hematoma formation at injection sites� Block does not resolve in 36 hours

sessed in terms of level of consciousness, and k

vailable support at home, not resolution oflock.1 Table 5 presents information thathould be provided before the patient is dis-harged.

onclusion

eripheral nerve blocks represent a majordvancement in patient comfort and safety inhe ambulatory surgical setting. Complica-ions are rare, and patients are very satisfied ineneral.1 The information presented in thisiscussion is intended to enhance the perian-sthesia nurse’s understanding and confi-ence when caring for patients who receiveeripheral nerve blocks.

cknowledgement

he author thanks Linda Bucher, DNSc, RN, Associate Profes-or at the University of Delaware and Nursing Research Facil-tator at the Christiana Care Health System in Newark, Dela-

are, for her support and encouragement in the developmentf this article.n addition, the author extends appreciation to Markounsbury, MD, partner in Outpatient Anesthesia Specialists,nc, and Medical Director of Limestone Ambulatory Surgeryenter in Wilmington, Delaware, for patiently sharing his

s Receiving Peripheral Nerve Blocks

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References

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1. Murauski JD: Peripheral nerve blocks for postoperativeanalgesia—Home study program. AORN J 75:136-147, 2002

2. Chelly JE, Greger J, Gebhard R, et al: Training of residentsin peripheral nerve blocks during anesthesiology residency.J Clin Anesth 14:584-588, 2002

3. Cox B, Durieux ME, Marcus MAE: Toxicity of local anes-thetics. Best Pract Res Clin Anaesthesiol 17:111-117, 2003

4. Olson JP: Clinical pharmacology made ridiculously simple(2nd ed.). Miami, FL, MedMaster, 2003

5. Mattewson-Kuhn M: Pharmacotherapeutics: A nursingprocess approach (4th ed.). Philadelphia, PA, F.A. Davis, 1998

6. Barnes S, Russell S: Interscalene blocks: care in the am-
bulatory setting. J Perianesth Nurs 19:352-354, 2004 M
7. Rodola F, Vagnoni S, Inletti S: An update on intravenousegional anesthesia of the arm. Eur Rev Med Pharmacol Sci:131-138, 20038. Rudkin GE, Rudkin AK: Ambulatory surgery acute painanagement: A review of the evidence. Acute Pain 7:41-49,

0059. Bannister M: Bier’s block. Anaesthesiology 52:713, 199710. Childs SG: Tension pneumothorax: A pulmonary com-

lication secondary to regional anesthesia from brachiallexus interscalene nerve block. J Perianesth Nurs 17:404-12, 200211. McCaffery M, Pasero C: Pain: Clinical manual. St Louis,
osby, 1999

KAREN L. McCAMANT24

Peripheral Nerve Blocks: Understanding the Nurse’s Role3.1 Contact Hours

Directions: The multiple-choice examination below is designed to test your understanding ofPeripheral Nerve Blocks: Understanding the Nurse’s Role according to the objectives listed. To earncontact hours from the American Society of PeriAnesthesia Nurses (ASPAN) Continuing EducationProvider Program: (1) read the article; (2) complete the posttest by indicating the answers on the testgrid provided; (3) tear out the page (or photocopy) and submit postmarked before February 28, 2008,with check payable to ASPAN (ASPAN member, $12.00 per test; nonmember, $15.00 per test); andreturn to ASPAN, 10 Melrose Ave, Suite 110, Cherry Hill, NJ 08003-3696. Notification of contact hoursawarded will be sent to you in 4 to 6 weeks.

Posttest Questions

1. Peripheral nerve block rotations are only offered in approximately ____ % of anesthesiaresidency programs.a. 28b. 38c. 48d. 58

2. The anesthetic effects of axillary, femoral, and popliteal blocks occurs primarily proximal tothe operative site.a. Trueb. False

3. The effects of regional anesthetics in peripheral nerve blocks is caused by interference withthe neuronal membrane’s permeability to:a. Calciumb. Magnesiumc. Potassiumd. Sodium

4. Pre-existing __________ may cause peripheral nerve blocks to behave unpredictably.a. Coagulopathiesb. Neuropathiesc. Allergiesd. Toxicities

5. Sensory disturbances such as blurred vision, tinnitus, and metallic taste are most commonlyassociated with _______ reactions to regional anesthetics.a. Toxicb. Allergicc. Delayedd. Immediate

6. It is normal to feel considerable resistance on the syringe plunger if the tip of the needle isproperly placed for the block.a. True
b. False


7. Physiological effects commonly associated with interscalene blocks include all of thefollowing except:a. Phrenic paralysisb. Ipsilateral papillary constrictionc. Hoarsenessd. Dyspnea

8. Intravenous regional, or Bier, blocks require the placement of ____ IVs.a. 0b. 1c. 2d. 3

9. The primary complications associated with Bier blocks are related to:a. Allergic reactionsb. Complaints of painc. Tourniquet failured. Oversedation

10. Patients should be instructed to call their physician if their block does not resolve in _____hours.a. 12b. 24c. 36d. 48

KAREN L. McCAMANT26

PERIPHERAL NERVE BLOCKS

ANSWERS

System W010208/2. Please circle the correct answer

1. a. 2. a. 3. a. 4. a. 5. a.b. b. b. b. b.c. c. c. c.d. d. d. d.

6. a. 7. a. 8. a. 9. a. 10. a.b. b. b. b. b.

c. c. c. c.d. d. d. d.

Please PrintName Nursing License No/StateAddressCity State ZipASPAN Member #

EVALUATION: Peripheral Nerve Blocks: Understanding the Nurse’s Role

(SD, strongly disagree; D, disagree; ?, uncertain; A, agree; SA, strongly agree) SD D ? A SA

1. To what degree did the content meet the objectives? 1 2 3 4 5a. Objective # 1 was met. 1 2 3 4 5b. Objective # 2 was met. 1 2 3 4 5c. Objective # 3 was met. 1 2 3 4 5

2. The program content was pertinent, comprehensive, and useful to me. 1 2 3 4 53. The program content was relevant to my nursing practice. 1 2 3 4 54. Self-study/home study was an appropriate format for the content. 1 2 3 4 55. Identify the amount of time required to read the article and take the test.

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Test answers must be submitted before February 28, 2008, to receive contact hours.

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Peripheral Nerve Blocks: Understanding the Nurse’s Role