Transcript Self-Learning Module Added Nursing Competency Patient

Self-Learning Module
Added Nursing Competency
Patient Controlled
Analgesia
Policy
Registered nurses are required to be
certified in the:
 Set up and monitoring of patients’ on
Patient Controlled Analgesia (PCA).
 If the registered nurse has not cared for
enough patients on PCA to ensure
competency, he/she must contact the
Acute Pain Nurse or Learning Services to
arrange education and review.
Standards
The Registered Nurse will:
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Complete the self-learning Module on Patient Controlled
Analgesia (PCA).
Review the Nursing policy on Patient Controlled
Analgesia 4.7.91.
Attend the in-service on PCA and complete a written
exam with a passing mark of 85%.
Demonstrate application of knowledge in the care of the
patient receiving PCA to the Acute Pain Nurse or
Learning Services. This includes performing a return
demonstration of the PCA device and identifying
appropriate patient assessment, documentation and
opioid delivery.
Purpose
Patient Controlled Analgesia (PCA) is the selfadministration of an analgesic within safe limits
as prescribed by an Anesthesiologist on the
Acute Pain Service or an ordering Physician
(Perth Hospital).
This learning module is designed to provide
registered nurses with the information
necessary to facilitate safe and effective care
of the patient receiving PCA.
Learning Objectives
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Define the concept of PCA.
Discuss the advantages of PCA
State the indications for PCA.
Understand the nurses role prior to starting PCA
Identify the ongoing nursing assessment and patient
education required for PCA
Identify the medications used for PCA including
dosage and potential adverse effects.
Understand the terminologies associated with the PCA
infusion pump.
Understand the procedure for programming and
delivering opioids via the PCA infusion pump.
Identify the possible complications, contraindications
and precautions associated with PCA.
Pain Management
RVH values effective pain management. The patient with pain is an active partner and
has choices to make regarding the management of their pain. Consider pain the fifth vital
sign and assess pain every time you check vital signs and more frequently if necessary.
The phrase “pain as the fifth vital sign” promotes an elevated awareness of pain
treatment among health care professionals. Quality care means that pain is measured
and treated.
The patients self-report is the most reliable indicator of pain. At RVH the standard
assessment tool used is the 0-10 pain intensity scale. For Pediatric patients the
Wong-Baker FACES with the 0-10 pain intensity scale is used. Acute post–operative pain
is a direct result of tissue damage caused by a surgical procedure. Acute post-operative
pain generally has a predictable pattern:
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It is characterized by a period of moderate to severe pain for a minimum of 48 hours
to 72 hours (depending on the type of surgery)
It is characterized by an increased intensity associated with activity
It is subjective and exists whenever the patient says it does.
It decreases over time with tissue healing.
Patient Controlled Analgesia
(PCA)
PCA is one way of managing acute pain in the hospital setting. PCA
leads to increased patient satisfaction and greater analgesic efficacy
when compared with intramuscular injections. A key principle of pain
management is that the individual who is experiencing the pain is the only
one who knows how intense it is. By giving the patient control over his or
her pain, the pain relief can be balanced with the degree of side effects
that may occur. PCA should be used as part of a multimodal approach to
pain management.
For this therapy to be effective, staff and patients should be fully
aware of how to use the infusion device and safety protocols must be
strictly adhered to. Careful patient screening and preoperative teaching
are essential. A key issue related to the success of the PCA is education
of the patient before its commencement and throughout its duration.
PCA Advantages
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Improved pain control
Decreased demand on nursing time; less time preparing injections
Decreased risk of needle stick injuries
Rapid onset of analgesia
Ability to rapidly administer analgesic prior to mobilization
Preservation of self control
Less tissue damage due to injections
Ease of breathing and coughing, improved respiratory function
Increased satisfaction with pain management
PCA eliminates the waiting period in a typical post-operative pain
cycle
PCA also eliminates wide fluctuations (peak and trough effects of
plasma analgesic drug concentration).
Indications for PCA
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PCA therapy is suitable for patients undergoing procedures where moderate to
severe postoperative pain is anticipated and where parenteral opioid administration
will be indicated. For short stay patients, who are on unrestricted diets shortly after
surgery, many can be well managed with oral analgesics. Sometimes, PCA is
ordered in addition to scheduled oral analgesics and used for breakthrough pain.
The person being considered for PCA must be able to understand the
relationship between pain, pushing the PCA button, and pain relief. The person must
also be capable of managing the equipment.
Pediatrics:
PCA can be used with children. The doses used must be appropriate for the
size and weight of the child. RVH has a PCA physician order sheet specific for the
pediatric population. A child must meet the same criteria as an adult: be able to
verbalize the concept of pain, be able to demonstrate understanding of the PCA
pump, be able to use the control button to give medication, be able to understand the
use of PCA and the use of medications to control pain.
Elderly:
PCA may be used in elderly patients, but the failure rate increases beyond the
age of 70 years. This may be secondary to the increased incidence of post-operative
confusion states in this patient population. Patients must be able to understand the
required instructions and retain that information into the postoperative period
How it Works
Patient Controlled Analgesia (PCA) is a
therapeutic modality that enables patients to self
–administer small doses of opioids intravenously
when they begin to experience pain. The patient
pushes a button (similar to a call bell) to activate
the device. The pump delivers a preset dose of
opioid into the patient’s intravenous (ex.
Morphine 2mg). The frequency of delivery is
controlled by an adjustable lockout period (ex. 5
minute lock out) that prevents another dose for a
preset time. Only the patient is allowed to push
the button. The four hour maximum dosage is
rarely programmed.
Nursing role prior to starting
PCA
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Provide an explanation to the patient or family on how to use IV PCA. Assess the patient’s level
of understanding on the use of PCA. Ensure the family is aware that only the patient can push the
PCA button.
Explain the use of the 0-10 pain intensity scale used in RVH. Ensure patient is aware that their
input is required for effective pain management. Pain is to be assessed at rest and with activity or
cough.
PCA is a modality that requires an independent double check by two RN’s who have completed a
competency for the management of PCA. The nurse who initially programmed the pump signs
their name on the Pain Flow sheet and notes that settings have been checked. Example of
nursing documentation on pain flow sheet:
Settings checked-Morphine 5mg/mL, 2 mg dose with 5 min L.O. K. Spragg, RN/
N. Schuttenbeld, RN
A second nurse must complete an independent check and verify that the settings have been
checked and co-sign.
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This independent double check is required:
When the PCA pump has been first programmed/ set up,
When the patient first arrives on the surgical unit for admission
When there is a change in PCA orders
When changing the PCA cassette
The nurse who initially programmed the pump signs their name on the Pain Flow sheet and notes
that settings have been checked. A second nurse must complete an independent check and
verify that the settings have been checked and co-sign.
Ongoing assessment
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While a patient is under the care of APS, registered nurses must not administer other analgesics or sedatives medications that have not been ordered or
approved by the APS (or in Perth Hospital, by the ordering PCA physician). Examples include Ativan, MS Contin, Restoril, etc. Please call APS to
obtain approval.
Assess the patient’s level of understanding using a verbal analogue scale (0= no pain, to 10= worst ever/excruciating pain). Assess pain both at rest and
with activity or cough. Assess if the pain medication gives relief and is acceptable to the patient.
Evaluate the patient’s level of understanding of the use of PCA for effective pain management. For example, do they understand to use PCA prior to
moving or ambulating to prevent pain?
Assess and document respiratory rate, sedation score and pain score every 2 hours for the first 24 hours and than every 4 hours and prn if required
more often.
Pain Scale:
Sedation Scores:
0= no pain
S= normal sleep, easily roused
2= mild pain
0= alert, awake
4= discomforting
1= drowsy, occasionally drowsy, easily roused
6= distressing
2= drowsy, repeated drowsy, easily roused
8= horrible
3= very drowsy, difficult to rouse
10= worst pain (excruciating)
4= unresponsive
Treat side effects as required and notify APS or PCA ordering physician if there is difficulty treating side effects. Assess and administer antiemetics for
any signs/reports of nausea.
Check the PCA pump settings at the beginning of every shift. Document that settings have been checked.
Check “history” to assess the patient’s pattern of PCA usage (the number of times the patient requests a dose versus how many times the patient
successfully receives a dose).
Evaluate the effectiveness of the PCA. You may need to re-instruct or clarify the use of the PCA device and reinforce appropriate use. If pain control is
not well managed, notify APS (or ordering physician in Perth hospital).
Pain Flow sheets are kept at the bedside for document and signing of all medications ordered by the Acute Pain Service. This includes any HS sedation
ordered, etc.
If the patient becomes very drowsy with a marked decrease in respiratory rate, follow the RVH standing orders:
If respiratory rate <8/min, and/or sedation score ≧ 3 implement the following:
Remove PCA button from patient
Rouse patient and encourage to breath
Start pulse oximetry and check pulse rate
Administer O2 by mask at 5L/min, and
Notify APS or PCS ordering physician.
If unresponsive, give Naloxone 0.1mg IV, repeat q 2-3 min prn.
Respiratory depression and
sedation
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Most patients will experience sedation at the beginning
of opioid therapy and whenever the opioid dose is
increased significantly. However, with opioid naïve
patients, excessive sedation that is untreated can
progress to clinically significant opioid induced
respiratory depression prompting the need for the
administration of Naloxone. Therefore, monitoring
sedation is the key to preventing opioid induced
respiratory depression.
Note: Significant opioid induced respiratory depression
occurs in less than 1% of patients using opioids.
Understanding how to prevent, assess and manage
respiratory depression will help you ensure both safe
and effective pain management.
IV PCA (Pump Settings
PCA Loading dose (Optional): Doses given in the PACU, ICU or on the ward
to bolus the patient with sufficient doses to reach a minimum effective
analgesic concentration prior to initiation of the PCA. In RVH, this is usually
not done through the PCA but by the RN in PACU.
Mode: The infuser delivers analgesia in one of three modes.
PCA mode: A bolus of opioid delivered only when the patient demands.
Continuous mode: At a preset continuous rate, no PCA dose available to the
patient.
PCA and continuous mode: A preset continuous rate plus PCA demands
available.
PCA Dose: The dose of analgesia administered each time the patient
activates the PCA device. Usual dose may be 1-2 mg morphine or 0.1 – 0.2
mg Hydromorphone.
Lockout Interval: The time between doses during which the patient cannot
activate the PCA (usually 5-10 minutes).
4 Hour Limit: The maximum dose limit allowed in a 4-hour period. (Not often
used but when used the “usual” dose limit may be 30-60 mg morphine). To
date, no evidence shows that the inclusion of these limits is of any benefit to
patients.
Background Infusions
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A background infusion is an opioid infusion that runs
continuously and is an addition to those opioids
administered by PCA. The literature supports that the
use of a background infusion demonstrates no
improvement in analgesia or sleep, but frequently
demonstrate increased opioid consumption and a higher
incidence of side effects, including sedation and
respiratory depression. Because of this potential for
dangerous respiratory depression, the routine use of a
background infusion is to be discouraged. If a
background infusion is used, nursing staff must be aware
that a patient is at increased risk for respiratory
depression and monitor the patient accordingly.
Steps to “Set Up” the Hospira
Lifecare PCA Pump
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Note: The PCA pump tubing is the primary line with a second line infusing into the PCA pump tubing at a rate TKVO to ensure flushing of the medication.
PCA tubing is located with IV tubing’s and also available through SPD. It is labeled PCA set with Injector, Mini-Bore List No. 3559-03.
Obtain PCA key.
Unlock PCA pump
Connect PCA pump tubing with integral anti siphon valve to cassette
Squeeze cradle release mechanism together at top of holder and move to the uppermost position.
Always confirm bar code window reader is clean before inserting vial.
Hold the vial with the graduate vial facing the clinician, this will ensure the bar code label faces the bar code reader on the right side of the vial compartment
Insert bottom of glass vial into the middle black bracket
(The number of milligrams on the vial should be facing forward).
Caution, do not load vial into upper vial clip first.-Vial lip may crack or chip
Gently press upper end of glass vial into upper black bracket.
Note: There will be a red flash as the bar code is read by the machine. This automatically turns the pump on. If vial bar code is not read by pump, slowly rotate the vial
and position with bar code on the right until barcode has been read.
Warning: Cracked vials may not show evidence of leakage until delivery pressure is applied. If the device is off, improper loading of syringe will turn on the device and
activate a non silenceable check syringe alarm within 30 seconds. Proper loading (engaging injector flange) will silence the alarm.
Squeeze the top of the cradle release mechanism and move down until the vial injector snaps into the bottom bracket
Select “Continue”
New Patient? Yes or no, select “Yes”
Confirm vial dose.
Purge? Select “yes”
Patient must be disconnected from the PCA set when activating the purge cycle.
Press and hold –Purge system (priming the PCA tubing)
Flow seen? _ Press YES or NO
Set loading dose: We do not use this function as patient has received loading dose in PACU.
Select delivery mode: PCA ONLY –unless otherwise ordered.
Enter PCA dose: select then press Enter
Lockout interval: select then press Enter
Set dose limit? Press “No” unless ordered.
Confirm “No Dose Limit” by pressing “Confirm” (Unless 4 hour dose limit is ordered)
Confirm settings as ordered by pressing “Confirm”
Confirm – The entered concentration (mg/ml) and drug name must exactly match the concentration value and drug name on the vial as ordered. If they do not match,
under/over dosage may result.
Lock door to start therapy
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Prime mainline I.V. tubing and connect to Y adaptor of PCA set. Prime lower portion
of PCA set with IV solution. Connect PCA tubing to extension tubing with
angiocath. Adjust flow of IV on mainline IV.
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- Prior to the initial dose, the patient’s vital signs and sedation score will be assessed and
documented on the patient’s chart.
- Change P.C.A. tubing every 72 hours in compliance with hospital policy re: I.V.
tubing. The PCA vial only requires changing when empty.
When PCA Doesn’t Work
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Assess the patient in a systematic manner to determine the cause. Rule out
technical problems, including errors in drug preparation, programming errors and
pump malfunction. Check if the medication is readily available to the patient. (If the
primary infusion is not running, check also the IV site).
Determine whether the patient is using the pump effectively. Is the patient
pushing the button appropriately? Some patients fear drug overdose and addiction.
Many patients are reluctant to use PCA because of severe side effects, one of the
more common ones being nausea. Many patients use the PCA effectively if reeducated and reassured about the safety of the technique, especially as it relates to
drug addiction and overdose. If a patient experiences inadequate analgesia despite
typical or higher than average PCA use, determine whether the problem lies with the
bolus dose, the lockout interval, unexpected opioid tolerance, exacerbation of the
surgical pain experienced, or another factor. Approach cautiously patients whose
opioid requirements are increasing at a time when they should be decreasing. Such
an increase may be an early indication of a surgical complication.
Supplement verbal instructions with teaching materials including the Patients’ Guide
to PCA handout. With proper teaching and appropriate monitoring, PCA is a safe
and effective method for providing post-operative pain relief.
Medications
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Opioid Vials: The prefilled PCA
cartridges (vials) supplied are Morphine
5mg/mL, Meperidine 10mg/mL, and
Hydromorphone 1mg/mL. Note:
Hydromorphone cassettes are premixed in
pharmacy at the DECRH in the CIVA
(central intravenous add mixture) program
and located in the Acudose.
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Morphine: A non-synthetic opioid analgesic. It is considered the
“gold standard” opioid for moderate to severe pain. It acts to control
pain by binding to opiate receptor sites in the central nervous
system (CNS) and blocks pain. It is thought to control pain by,
Elevating the pain threshold
Interfering with pain conduction or CNC response to pain
Altering the patient’s pain perception
Onset of intravenous Morphine is 5-15 minutes
Contraindications: Known hypersensitivity to drug, head injuries
(ICP, depressant effect on respiration), acute bronchial asthma
Side effects include nausea, vomiting, constipation, urinary
retention, postural hypotension, allergic reactions, including uticaria,
skin rash, asthma, and behavioral changes such as restlessness,
excitement, tremors, disorientation, confusion, hallucinations.
Dosage: PCA Morphine is available in 30 ml pre-filled cartridges
(vials) in a concentration of 5mg/mL). “Usual” dose ordered is 2mg
every 5 min as required.
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Hydromorphone (Dilaudid) - A pure agonist opioid analgesic used
for the relief of moderate to severe pain. Hydromorphone is 5-10
times more potent than Morphine on a milligram to milligram basis.
Hydromorphone has a more rapid onset of analgesia than morphine,
but its duration of action is usually shorter.
Onset: of intravenous Hydromorphone is 5 minutes.
Contraindications: Hypersensitivity to opioid analgesia, acute
respiratory depression, acute asthma attack, and upper airway
obstruction.
Side effects: Most commonly requiring medical attention includes
sedation, nausea and vomiting, constipation and sweating. Others
include respiratory depression, urinary retention, euphoria and
dysphoria, weakness, headache.
Dosage: PCA Hydromorphone is available in 30 mL pre-filled
cartridges (vials) in a concentration of 1mg/mL. “Usual” dose is 0.10.2mg every 5 minutes as required.
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Meperidine/Demerol – A synthetic opioid analgesic. A dose of 10mg to
20mg of Demerol is similar to morphine 1mg to 2mg in onset of action and
duration. Indications, actions and side effects are also similar. Meperidine is
metabolized primarily in the liver. Demerol may be appropriate for patients
unable to tolerate Morphine. A major drawback to the use of meperidine is
its active metabolite, normeperidine. Normeperidine is a CNS stimulant and
if accumulation of this metabolite occurs in the body, it can have toxic
effects on the central nervous system. Normeperidine causes effects from
dysphoria, twitching, agitation, to hallucinations and seizures.
Normeperidine has a half-life of 15 to 20 hours compared with Meperidine’s
half-life of 3 hours.
Note: Best practice guidelines (RNAO, 2007) do not recommend
Meperidine for the treatment of pain.
Meperidine is contraindicated in persistent pain due to the build up of the
toxic metabolite normeperedine, which can cause seizures and dysphoria.
Meperidine toxicity is not reversible by naloxone.
Meperidine has limited use in acute pain due to a lack of drug efficacy and a
build up of toxic metabolites, which can occur within 72 hours
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Contraindications: Known hypersensitivity to
drug, head injuries, in patients receiving MAO
inhibitors or those who have received such
agents within 14 days (can cause excessive
prolonged CNS depression with cardiovascular
instability, restlessness and convulsions) and
convulsive disorders. Not recommended for long
term use.
Meperidine is not recommended in the presence
of renal or hepatic insufficiency, in the presence
of CNS disorders or in the elderly population.
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Usual dosage: PCA Demerol is available
in 30 ml pre-filled cartridges (vials) in a
concentration of 10mg/mL. “Usual” dose
ordered is 10 mg- 20 mg every 5 minutes
as required.
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Cautious Use: Opioids are potent
respiratory depressants; therefore they
must be given with caution and
appropriate monitoring. Drug dependence
is a theoretical concern, but is extremely
rare when opioids are used for the
management of acute pain. Excessive
concern about respiratory depression and
addiction are factors in the under
treatment of acute pain.
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Naloxone (Narcan): Opioid antagonist. Must be available on all
units where PCA is being administered. Naloxone is part of the
standing orders on the PCA physician order sheet.
Prevents or reverses the effects of opioids including respiratory
depression, sedation and hypotension. It is indicated for the
complete or partial reversal of opioid depression, or for the diagnosis
of suspected acute opioid overdose. Naloxone is not effective for
depression due to barbiturates, tranquilizers or other non-opioid
sedatives.
Dose: for post-operative opioid depression is 0.1mg IV every 2-3
minutes. For opioid overdose 0.4 –2mg IV q 2-3 minutes PRN.
Onset of action: within 2 minutes.
The duration of action of Naloxone is shorter than the length of
action of opioids and respiratory depression can reoccur. Monitor
the patient closely. Repeated doses of Naloxone should be
administered as necessary.
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Adjunctive Medications:
Orders for the management of side effects are written at
the same time as the PCA order and will include antiemetics and antipruritics.
The administration of NSAIDS, or acetaminophen
when possible, as adjuncts to postoperative parenteral
opioids, is recommended. NSAID’s consistently reduce
the PCA opioid requirements following many surgical
procedures. A reduction in opioid consumption may be
accompanied by improved analgesia and a lower
incidence of side effects, especially nausea and
sedation. Combining analgesic drugs with different sites
of action enhances pain relief.
PCA Test
Name: ________________________________________ Date: _______________
1. Patient education of PCA therapy by the RN will occur:
a). In PACU before initiation of PCA
b). During the preoperative period
c). In the postoperative period when the patient returns to the nursing unit
d). When the patient is having difficulty understanding PCA therapy
1). b, c
2). a, c, d
3). a, b, c, d
2. The frequency of which a patient may receive a specific PCA dose of analgesia is known as:
1). 4 hour dose limit
2). PCA dose
3). Lockout interval
4). Loading dose
3. When is it necessary to check the PCA settings with another RN and co-sign on the pain flow
sheet?
a). at the beginning of each shift
b). when PCA is first ordered
c). when PCA settings are changed
d). when the PCA cassette is changed
1). a, b, c
2). b, c
3). a, b, c, d
4). b, c, d
4. Your patient Mr. Retallick, 45, has been receiving PCA therapy for 3 daysMeperidine (Demerol) 10mg/ml
PCA dose of 20 mg
Lockout of 5 min
4 hour dose limit of 200mg
Mr. Retallicks’ consumption of Demerol is consistently close to the 4-hour limit. Today you notice a new hand tremor. You
ask him how he feels and he says “jumpy”. Mr. Retallick doesn’t wish to d/c the PCA, as he is NPO.
Do you need to report your findings to the APS? Yes ____ No ____ and why / why not?
5. If you answered yes, which one of the following options would be most appropriate in this situation?
a). ask the APS to decrease the PCA dose back to 10mg every 7 minutes.
b). request that PCA be discontinued and the patient ordered Demerol 75-100mg IM q4 hrs post-op.
c). tell Mr. Retallick that he is using too much and to use less. This is has third day and the pain should be decreasing.
d). request a change to an alternate opioid.
6. List three items of information about PCA that the patient should know.
__________________________________________________________________
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7. Describe the action of Naloxone ______________________________________
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8. Describe the actions to be taken if the patient is receiving inadequate pain relief?
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9. Program the PCA pump for:
a). Morphine 3mg dose, seven minute lock out, no 4-hour dose limit.
b). Morphine 1mg dose, ten minute lock out, 4-hour dose limit of 40mg.
c). Hydromorphine 0.2 mg dose, 5 minute lock out, no 4 hour dose limit.