Self-Learning Module Added Nursing Competency Patient Controlled Analgesia

1. Self-Learning ModuleAdded Nursing CompetencyPatient Controlled Analgesia

2. 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.

3. 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.

4. 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.

5. 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.

6. 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: • 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.

7. 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.

8. 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).

9. 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

10. 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.

11. Nursing role prior to starting PCA • 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. • 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.

12. 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 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.

13. 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.

14. 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.

15. 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.

16. 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 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 • 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. •  - 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.

17. When PCA Doesn’t 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. Withproper teaching and appropriate monitoring, PCA is a safe and effective method for providing post-operative pain relief.

18. 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.

19. 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.

20. 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.

21. 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

22. 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.

23. 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.

24. 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.

25. 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.

26. 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. 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.

27. PCA TestName: ________________________________________ Date: _______________1. Patient education of PCA therapy by the RN will occur:a). 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 as:1). 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

28. 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 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.______________________________________________________________________________________________________________________________________________________________________________________________________ 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 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.