Patient Controlled Analgesia (PCA) Infusions

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Patient Controlled Analgesia (PCA) Infusions
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Definitions

• The patient controlled analgesia (PCA) device is
  a method of providing intravenous (IV) and
  subcutaneous (SC) opioids that will potentially
  improve pain management for the patient and
  provide a better sense of personal control over
  pain. The PCA device is able to provide
  incremental doses and/or continuous infusion
• Opioid Naïve Those patients who have not been
  taking opioids regularly. Most surgical patients
  and trauma victims would be considered opioid
  naïve (McCaffery Pasero, 1999).
• Opioid Tolerant Those patients who have used
  opioids regularly for approximately 7 days or
  more (McCaffery Pasero, 1999)

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PCA and RN Responsibility

• RNs managing patients with a PCA infusion must
  have completed the annual pain competency. Annual
  competency will demonstrate equipment competency.
  
• RNs may administer PCA per MD order and
• a. Initiate PCA infusion,
• b. Change PCA syringe,
• c. Bolus via the PCA pump (ALL rescue doses must
  be delivered through pump)
• d. Discontinue an infusion.

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PCA and RN Responsibility

• Two RNs must perform and document independent
  double checks and verify orders per medication
  policy when initiating or changing administration
  of PCA medication.
• Instruct patient/family on correct use of the
  PCA pump, using age and language appropriate
  materials. Emphasize that only the patient,
  including children, are to administer the
  incremental dose. Staff who become aware of PCA
  supplementation by anyone other than the patient
  should report this to physician and document
  clearly. Document all patient education on
  appropriate form.

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Monitoring and Documentation

• The 24-hour pain management flow sheet is
  considered procedure for monitoring and
  documentation of this policy. Specific
  documentation instructions are provided on the
  flow sheet.

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Disposal of Unused Med

• Any unused medication remaining in the PCA pump
  should be wasted, witnessed, and appropriately
  documented per medication policy

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Continuous (basal) Infusions

• Pulse Oximetry mandatory for 1st 24 hrs
• For pediatric population, consider continuous
  pulse oximetry for high risk groups, such as
  patients less than 5 years of age and opiod naïve.

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Side Effects of Opioids

• Constipation
• Nausea
• Vomiting
• Pruritis
• Sedation
• Respiratory Depression

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Assessment

• Respiratory rate assessment includes RATE,
  DEPTH and RHYTHM.

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PCA Risk Factors for Respiratory Depression

• age greater than 70 years
• basal infusion with IV/PCA
• renal, hepatic, pulmonary, or cardiac
  impairment
• sleep apnea (suspected or history)
• concurrent central nervous system depressants
• Obesity
• upper abdominal or thoracic surgery
• IV PCA bolus gt1 mg.
• (Hagle, et al, 2004)

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Nocturnal Monitoring

• Nocturnal Hypoxia is a risk
• Assess rate, depth and rhythm of respirations
  while patient is ASLEEP!
• Do not awaken and then assess!
• Patients with induced respiratory depression or
  over sedation can easily be stimulated to a
  higher level of consciousness and an increased
  respiratory rate! (Nurse Advise-ERR, 1/2005)

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Pediatric Considerations

• Risk factors for respiratory depression with
  IV/PCA include Less than 2 months of age
  hemodynamic instability renal insufficiency
  hepatic dysfunction IV PCA Morphine continuous
  infusion of more than 20 micrograms/kg/hr
  concomitant administration of sedatives,
  hypnotics, and antihistamines and concurrent use
  of continuous background or basal opioid
  infusions.
• Contraindications to Pediatric PCA use
  Inability to activate device understand
  concepts of self-administration understand and
  report pain relief obtained and hemodynamic
  instability, which may cause opioid-induced
  hypotension and cardiovascular effects.
• Cognitive, developmental, and physical ability
  considerations Child must understand concepts of
  stimulus (pain), response (pushing button), and
  delayed result (pain relief). Goal is pain
  control and relief, not elimination of pain.

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Adult Pain Management Flow Sheet

• Slides 13 and 14 are pages from the Adult Pain
  Management Flow Sheet which should be used to
  answer questions 8,9 10.
• If you would like additional information on PCA
  Infusions pleas click on the following policy
  link
• Policy C-55 PCA Infusion

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PCA Question 1

• 1. Patients who have not been taking opiods
  regularly are referred to as
• A. Opiod tolerant
• B. Opiod naïve
• C. Opiod free
• D. Sober

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PCA Question 2

• 2. RNs may
• A. Initiate a PCA infusion
• B. Change the PCA syringe
• C. Bolus via the PCA pump
• D. All of the above

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PCA Question 3

• 3. When initiating or changing doses in the PCA
  pump the RN must perform an independent double
  check with another RN
• A. T
• B. F

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PCA Question 4

• 4. A 14 yo has a PCA pump. Who may operate the
  pump to administer incremental doses to this
  patient?
• A. The patients parents
• B. The patients legal guardian
• C. The patient
• D. All of the above

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PCA Question 5

• 5. Any unused medication remaining in the
• the PCA pump should be wasted
• and witnessed like any other narcotic waste
• A. T
• B. F

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PCA Question 6

• 6.Side effects to monitor when a patient is on
  PCA therapy include
• A. Nausea, vomiting
• B. Pruritis
• C. Sedation, respiratory depression
• D. All of the above

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PCA Question 7

• 7. The nurse should assess rate, depth and
  rhythm of respirations while the patient is
  asleep because
• A.Patients on PCA therapy are at risk for
  nocturnal hypoxia
• B.Nocturnal hypoxia can only be assessed while
  patient is sleeping
• C.Both A and B
• D.None of the above

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PCA Question 8

• 8. According to the Adult Pain Management Flow
  sheet (slides 2 3), monitoring the sedation
  score of patients receiving PCA therapy is vital
  because sedation precedes respiratory depression.
• A. True
• B. False

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PCA Question 9

• 9. According to the Pain Management Flow sheet
  (slides 2 3), after initiation of PCA therapy,
  the patients pain score, respiratory rate and
  sedation score should be monitored
• A. q1h x 12, q 2h x12, then q 4h
• B. q 30 min x 12, then q 4 hours
• C. q 2h x 12, q 4h x 12 then q 8h
• D. q1h x 4 then q 4h

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PCA Question 10

• 10. According the Adult Pain Management Flow
  Sheet (slides 2 3), after initiation of PCA
  therapy oxygen saturation should be monitored
• A. Continuously for first 24 hours
• B. At least every 4 hours after first 24 hours
• C. ½ hour after any order change
• D. All of the above