Patient Controlled Analgesia
What types of things are we monitoring?
- Respiratory Status - Respiratory rate - Oxygen saturation continuous monitoring (SpO2 level or CO2 level , Alaris pump has SpO2 and CO2 modules that connect to the pump) - Sedation level (POSS) - Pain level -to monitor effectiveness of PCA pump - Some facilities require charting of the number of times button was pushed and number of doses patient received-to monitor effectiveness of PCA settings.
What do you do when a PCA is discontinued?
you will need to waste the remaining amount of narcotic in the pyxis with another RN
What is the basal rate?
- (aka continuous rate) can also be ordered in addition to PCA demand dose. In this case the patient would receive a low dose continuous infusion of the medication AND have the ability to self deliver bolus doses. - Usually used for patients w/chronic pain - Not recommended for opioid-naïve patients - May lead to serious respiratory depression
What is a hour interval (lockout)?
-is the maximum amount of opioid a client can receive in an hour-limit period. This is an additional safety feature to limit the amount of medication delivered. (at JM we do 4 hour interval) ( Our Alaris pump has 1 hour interval the Plum pump as 4 hour interval) Example: Morphine 1mg dose every 8 minutes with a 4 hour lock-out of 16mg -in report you may hear RNs saying 1/8/16. Another way to verbalize this order is: Morphine 1mg with an 8 minute delay and a 4hr dose limit of 16mg
How do we wean patients off of PCA?
-start PO opioids when pain under control (after 24 hrs initiating pca) - PO opioids-->longer pain relief (especially during sleeping)
What are some advantages to PCA?
- Allows patients to treat their pain by self administering doses of analgesics - Minimizes the roller-coaster effects of ups and downs with pain and sedation that often occur with traditional method of PRN dosing*** - Patients maintain a more CONSTANT level of relief yet require LESS medication for pain relief-because patients are experiencing better pain control***
What are bolus doses?
- Can be given if in MD orders - Is a separate dose from the # doses patient is allowed to give to self - Used to treat severe breakthrough pain - Is programmed into the pump to give immediately as a one time dose
What are some adjunct pain therapies to PCA?
- If a post-op patient check order for any adjunct therapy that will play a role in decreasing pain such as ice packs, limb elevation, immobilization, range of motion. This will help with overall pain control and amount of medication needed from PCA. - Provide non-pharmacological interventions such as massage, music therapy, (at JM we have a comfort music channel on TV), meditation, prayer (can request for pastoral services as well), pet therapy (at JM we have volunteer therapy dogs),
What sites can PCA be used with?
- Intravenously (peripheral, central) - Epidural: Called patient controlled epidural analgesia (can used be during labor, for acute surgical pain, cancer pain)
Meds often used with a PCA pump...
- Morphine (vials 1mg/mL) - Hydromorphone-Dilaudid (vial 0.2mg/mL) - Fentanyl (less commonly used for acute pain)
What do we chart on?
- Respiratory status & rate - O2 saturation - Sedation level - Pain level - Patient's PCA settings - How much of the medication was used to prime the tubing (all narcotic needs to be accounted for) - Shift totals- how much patient used at the end of each 8 hour shift (8 hour shift totals even if you're working 12 hour shift). You will have to clear the pump of the shift total every shift in order to keep track of how much they're getting. This task requires a PCA key. - Pass on shift totals to the RN taking over for your patient at shift change - Any time a PCA is discontinued -Patient education (what you taught them, method, if patient understood teaching) -Adding PCA to care plan
What are some PCA safety precautions?
- Since patient controls own medication administration-patient has to be awake, alert and oriented. - Has a lock. Requires a key for opening the clamp that goes around IV pole and for opening the door to the chamber that holds medication syringe - this is so no one can steal the pump or the syringe. - PCA keys are kept in pyxis, limited number per unit, please return to pyxis after use for next RN to use. - PCA chamber has a barcode scanner installed. When syringe loads into the pump, the scanner will automatically scan the barcode of the drug and verify the correct drug has been selected when it was programmed. -All PCAs require co-signing, it is a safety stop to double check settings on PCA pump -Patient education-patient needs to understand how to use PCA and risks involved -Patient monitoring (vital signs, sedation level, pain level, etc)
When to co-sign a PCA?
- The pump is first initiated - When the medication syringe is empty & a new one is being placed - Any time settings are changed - Any time a bolus from the PCA is given - At change of shift btwn bedside RN's - Refer to facility policy
Which patients are at the highest risk of serious respiratory depression when using a basal rate?
- those at highest risk are: older age patients, obstructive sleep apnea, pulmonary disease. - Basal rates may not be used with these populations or used with extreme caution.
Diuladid is how many times more potent than morphine?
7-10 times more potent
Who has control over the PCA pump?
Controlled by the patient ONLY (not family) A dose of opioid is delivered intravenously when the patient decides a dose is needed by pushing a button.
Types of administration
Loading dose PCA demand dose Basal rates Bolus doses
What are some dangers of PCA?
Make sure to: give correct med & concentration program pump correctly set lock out function correctly
Can PCA tubing share the line with other medications?
No, no other medication goes through PCA tubing. If other medication is necessary, another IV access will be needed.
What type of patient should not be on PCA?
Not used with confused patients, sedated patients or children (depends on age/development)
What are the risks involved with PCA?
Over sedation- especially for opioid-naïve patients. Patients may be difficult to arouse
PCA is often part of an order set, what other medications are typically added to the order set?
Over sedation--> narcan Nausea-->zofran Itching-->benadryl Constipation-->decussate sodium
Lock Out Interval
PCA bolus doses are given in intervals with a lock out time which is the amount of time that must pass between PCA doses. This is also called a "delay" The lock out interval is usually set at 6 or 8 minutes for postoperative patients which means the patient can give themselves a dose of medication every 6 or 8 minutes. Even if the patient pushes the button more frequently, he or she will receive only one bolus dose during the lock out interval. Example: Morphine 1mg dose every 8 minutes (if the patient pushes the button 5 times, they will get the medication on the first push if able, the next 4 pushes will not provide any medication if done in the 8 minute period)
What is involved with patient monitoring during PCA usage?
Physical monitoring of the patient & documentation of findings into chart. Typically every 2-4 hours for the first 24-36 hours (depending on facility policy)
What to do if an elderly patient states they feel "loopy" or "out of it"?
Reassess need for PCA, settings and alternative options for pain relief.
What do you need for patient controlled analgesia?
Requires a special pump (PCA pump) and PCA tubing
Why are co-signs required for PCA?
Safety: ensures PCA orders match the PCA programming on pump.
What to do if a patient is difficult to arose?
Take vital signs & call MD, may need to decrease dosage of PCA , remove basal rate if they are on one, or discontinue PCA altogether. May need narcan.
What is PCA used for?
Widely used for the management of acute pain, postoperative and cancer pain
What is a PCA demand dose?
amount of medication the patient will receive when a dose is self-administered by pushing the button)
What to do if patient has respiratory depression?
decreased respiratory rate (8-10), shallow breaths, decreased O2 saturations Put O2 on the patient & call MD. May need narcan.
What is a loading dose?
given at the start of the infusion, programmed into the pump at initial start up, usually a larger dose than the PCA bolus dose, given to patients in severe pain needing immediate relief.
What to do if your patient has low blood pressure while on PCA?
orthostatic hypotension, especially prominent when patient gets out of bed to work with physical therapy or to use bathroom, patient may complain of dizziness and break into a sweat. What to do? Put patient back to bed. Assess continued need to PCA, consider transitioning patient off of PCA with the use of oral pain medications. Instruct patient to not get out of bed alone.
Why is it important to properly prime the PCA tubing?
properly priming tubing helps to prevent a large bolus from entering the patient.
