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What are the reason for using a PCA or Epidural?
- Better pain control
- Patient will be able to ambulate earlier
- patient will be satisfied with a better pain relief
What's the definition of Patient Controlled Analgesia?
Client can controls IV delivery of an analgesic by pressing the button on a delivery device
When is a PCA used?
- trauma pain
- sickle cell crisis
- chronic pain
Which patients are better candidates for a PCA?
- be able to learn how to use, why use, and when to use
- physically able to use the pump
What are the most common used medication in a PCA?
What are 8 advantages of having a PCA?
- 1. Constant serum levels of opioid
- 2. reduce dose of opioids used
- 3. better pain relief
- 4. fewer side effects from opioids
- 5. decreases complication with patient
- 6. No need for any IM analegesics
- 7. allows client to sleep at night while minimizing daytime drowsiness
- 8. client becomes independent
What are 5 disadvantages of having a PCA?
- 1. patient doesn't get pain relief because they mistake the button for another button
- 2. patients family comes in and uses it
- 3. pump fails from not giving the right amount of dose
- 4. nurse inaccurately set up the pump
- 5. nurse fails to continue monitoring the patient
If a patient experiences and overdose from a disadvantage of the PCA pump what is the nurse going to administer?
What is one condition that is contraindicated for using a PCA due to increasing the risk of respiratory depression?
What's the initial thing a nurse has to do with a PCA at the beginning of the shift?
check the HISTORY button and compare to MD order
What is the loading dose?
- initial dose to get medication on board.
- 1 time dose only
What is the basal infusion rate?
continuous infusion rate 0.5 ml/hr
What is the PCA dose?
the demand dose- the dose the patient gets every time they push the button
what is the bolus dose administered by RN?
A dose given for breakthrough pain
what is the 1-4 hour dose limit?
the maximum dose amount the patient can receive including (basal rate, pca dose, loading dose, bolus)
What is the lockout interval?
time patient has to wait between each dose they get 8-10 mins
What are the things you need to educate the patient about when it comes to a PCA?
- 1. medication
- 2. purpose and benefits of pca
- 3. side effects & when to notify RN
- 4. Goal for pain control
- 5. How to use PCA
- 6. When to use PCA
- 7. Lockout interval/PCA dose
- 8. Inability to overdose
What are the steps in setting up the pump?
- 1. attach the pump to a pole 10 inches above infusion site
- 2. attach med syringe and prime PCA tubing with medication
- 3. prime primary iv line with NS and insert to IV pump
- 4. Connect tubing from PCA pump to primary line at Y site closest to patient
- 5. set pump according to MD orders
Is the usage of a PCA Pump have to be verified by one or two nurses?
2 rns independently verify medication, dose, rate
What are the steps in changing the medication syringe?
- 1. 2 nurses needed to verify
- 2. check MD orders
- 3. obtain correct med
- 4. raise top bracket-remove old syringe
- 5. uncap new syringe-place in chamber & slide down bracket
- 6. change tubing if changing new med
What are the essentials the nurse needs to monitor within 1 hour of giving loading dose and EVERY 2hr for the first 24hrs then Q 4HRS & PRN?
- respiratory rate
- sedation level
- 02 stat
- VS-BP, pulse
- iv access
- s/sx of overdose
When should the amount of med delivered, # of attempts, delivery of PCA demand dose, and basal dose be evaluated?
every 4 hours
When should the patients pain intensity, sedation level, respiratory rate and O2 stats be evaluated?
- within 15 minutes of first dose, if the concentration or rate change, any pump change, any supplemental narcotic or sedatives given
- then every 2 hours for the first 24 hours then every 4 hours until pca discontinued
When should the nurse document and monitor the medication, dose, basal rate, #of injection, # of attempts, total narcotics given?
every 8 hours
When a nurse is assessing a patient for a sedation level how is the sedation scale interpreted??
- 1=awake and alert
- 3=arouses to verbal stimuli only
- 4=arouse to physical stimuli only
- 5=somnolent/difficult to arouse
What are two standard orders (things that are not to be done) when using a PCA?
- 1. Meperidine (Demerol) should NOT be used in a PCA
- 2. NO additional IV/IM/PO narcotics should be given unless ordered by MD
What should the nurse do if the clients pain continues or gets worse?
- assess patients pain (PQRSTU)
- make sure the primary fluid is running
- look at the # of delivers vs. attempts
- assess for any other complications
- check iv site for kinked or infiltrated
What should the nurse do when the MD has ordered for the PCA to be discontinued?
- 1. Give PO meds before PCA is discontinued
- 2. take away the button
- 3. give them the basal dose
- 4. give them PO
If a patient becomes overmedicated how can you explain the reason for this to their family and what should the nurse do?
- happens from patient pressing the PCA button to many times
- nurse stops dosage
- sit patient up and ask them to take deep breaths
- give patient supplemental oxygen
Is it safe to use a PCA on a pediatric patient?
- yes for the age of 8-9
- as long as they understand the concept
What should a nurse know about a PCA given to an elder patient?
- sensitive to analgesic properties this is a side effect of opioid
- they have slow opioid metabolism and excretion
- should start low and go slow
What is the definition of an epidural administration of analgesic?
catheter inserted into potential space
when is a epidural used?
- post op
- abdominal surgery
What are the most common used medications used in a epidural?
- local anesthetics
how does an epidural work and deliver medication?
- medication is delivered through diffusion thru dura mater in CSF
- blood vessels in epidural space transport med systemically
- med is absorbed by fat in epidural space creating a depot for slow systemic release
What are the 4 advantages of a epidural?
- 1. lower total dose of opioids required to control pain
- 2. fewer side effects to opioids
- 3. client can ambulate earlier
- 4. client is less drowsy
What are the 5 disadvantages of having a epidural?
- 1. increase risk of respiratory distress
- 2. catheter may migrate into subarachnoid space causing dangerously high levels of med
- 3. urinary retention
- 4. motor or sensory changes
- 5. require frequent monitoring
Beside a patient having a epidural what other patients are at increased risk of developing respiratory distress?
- age >70 yrs
- receiving concurrent CNS depressants
- renal, hepatic, cardiac impairment
- pulmonary impairment (sleep apnea, ICP, COPD, asthma)
- upper abdominal or thoracic surgery
what are contraindication for a patient to have a epidural?
- use of anticoagulants
- taking herbal meds
- has abnormal clotting studies
- history of multiple abscesses
- skeletal or spinal abnormalities
Which type of pump and tubing used for an epidural?
- EPIDURAL ONLY pump
- tube with no Y-ports
How often should a patients SpO2 be monitored while with a epidural?
continuous monitoring until 12 hours after infusion discontinued
How often should the nurse monitor a patients pain intensity, sedation level, respiratory rate with a epidural?
- within 15 minutes of first dose, if the concentration or rate change, any pump change
- then every 1 hour for the first 24 hours then every 2 hours until 12 hours post discontinued
How often should the catheter insertion site, motor/sensory function/CMST of lower extremities, BP and Pulse, and temp?
Every 8 hours and PRN
What are some common side effects the nurse should be aware that could happen from an epidural?
- 1. urinary retention/constipation
- 2. nausea/vomiting
- 3. pruritis
- 4. headache
If a patient has a epidural what is important for a nurse to make sure is within reach?
- 1. oxygen equipment
- 2. bag/valve/mask
- 3. narcan
Where is the best place for a patient to be with a epidural?
near the nurses station for frequent monioring
What is the priority of the nurse to check before the patient is first going to ambulate?
When it is important for a nurse to notify the anesthesiologist?
- -change in CMST
- -continued dizziness
- -increased heart rate/lightheadness with decrease in BP
- -problem with catheter line
What should the nurse do if the catheter becomes disconnected or sterility is compromised?
- 1. turn off pump
- 2. cover end of catheter with a sterile cap
- 3. DO NOT reconnect catheter
- 4. keep catheter intact
- 5. call anesthesiologist
Is it okay for epidural to be used in pediatric population?
- OK for all ages
- dose is per kg
- requires continuous cardiac, respiratory, and O2 stat monitoring
If an elder patient has an epidural what should the nurse be aware of?
hypotension especially if patient is taking antihypertensives
For PCA & Epidural administration what is important for the nurse to understand?
- They provide acute pain control
- how to administer correct medication dosage
- interpret orders
- knowing the equipment
- assessing patient for pain and side effects
- teaching patient how to use PCA