SelfLearning Module Added Nursing Competency Patient Controlled Analgesia

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Self-Learning ModuleAdded Nursing
CompetencyPatient Controlled Analgesia
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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.

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Standards

• The Registered Nurse will
• 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.

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Purpose

• Patient Controlled Analgesia (PCA) is the
  self-administration 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.

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Learning Objectives

• 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.

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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 postoperative pain
• is a direct result of tissue damage caused by a
  surgical procedure. Acute post-operative
• pain generally has a predictable pattern
• 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.

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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.

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PCA Advantages

• 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).

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Indications for PCA

• 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

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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 patients
  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.

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Nursing role prior to starting PCA

• Provide an explanation to the patient or family
  on how to use IV PCA. Assess the patients 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 RNs 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.
• 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.

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Ongoing assessment

• 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 patients 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 patients 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 patients 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 lt8/min, and/or sedation score
  ? 3 implement the following
• Remove PCA button from patient

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Respiratory depression and sedation

• 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.

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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.

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Background Infusions

• 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.

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Steps to Set Up the Hospira Lifecare PCA Pump

• 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 tubings 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

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When PCA Doesnt Work

• 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 re-educated 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.

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Medications

• 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 patients 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 0.1- 0.2mg 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
  Meperidines 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 anti-emetics and antipruritics.
• The administration of NSAIDS, or acetaminophen
  when possible, as adjuncts to postoperative
  parenteral opioids, is recommended. NSAIDs
  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.

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PCA TestName ___________________________________
_____ Date _______________1. Patient education
of PCA therapy by the RN will occura). In PACU
before initiation of PCAb). During the
preoperative periodc). In the postoperative
period when the patient returns to the nursing
unitd). When the patient is having difficulty
understanding PCA therapy1). b, c2). a, c, d
3). a, b, c, d2. The frequency of which a
patient may receive a specific PCA dose of
analgesia is known as1). 4 hour dose limit2).
PCA dose3). Lockout interval4). Loading dose3.
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 shiftb).
when PCA is first orderedc). when PCA settings
are changedd). when the PCA cassette is
changed1). a, b, c2). b, c3). a, b, c, d 4).
b, c, d
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4. Your patient Mr. Retallick, 45, has been
receiving PCA therapy for 3 days-Meperidine
(Demerol) 10mg/mlPCA dose of 20 mgLockout of 5
min4 hour dose limit of 200mgMr. 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 doesnt 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.____________________________________________
_________________________________________________
_________________________________________________
__________________________________________________
______ 7. Describe the action of Naloxone
_________________________________________________
__________________________________________________
_________________________________________________
______________________8. Describe the actions to
be taken if the patient is receiving inadequate
pain relief? ____________________________________
_________________________________________________
__________________________________________________
_________________________________________________
____________________9. Program the PCA pump
fora). 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.