LEARNING MODULE FOR PATIENT CONTROLLED ANALGESIA. Acute Pain Management. QEII Health Sciences Centre and Dartmouth General Hospital

Transcription

1 LEARNING MODULE FOR PATIENT CONTROLLED ANALGESIA QEII Health Sciences Centre and Dartmouth General Hospital (CC ) Developed by: Acute Pain Service QE II Health Sciences Centre Perioperative Portfolio Date: August 11, 1997 Revised: November 2000 January 2003 January 2007 February 2011 Patient Controlled Analgesia CC Page 1 of 14

2 TABLE OF CONTENTS Page 1. Introduction 1.1 Purpose Learning Objectives 3 2. Method 3 3. Prerequisites 3 4. Theory Definition Indications Role of Acute Pain Service Patient Education Drug Information commonly used PCA opioids and settings 5 - medications used to treat side effects 6 - multimodal 6 5. Nursing Implications Patient assessment 5.2 Pain level 5.3 Respiratory depression and sedation 6. Test Proficiency Standard Skills Checklist 13 Patient Controlled Analgesia CC Page 2 of 11

3 PURPOSE Patient Controlled Analgesia (PCA) is a delivery system where patients self administer prescribed doses of opioids by means of a programmable pump. Doses are prescribed by an APS physician and individualized for the patient. This is designed to provide nurses with the information necessary to facilitate safe and effective care of the patient receiving PCA for pain management. LEARNING OBJECTIVES Following completion of the required learning activities, the Registered Nurse will be able to: 1. State the indications for PCA. 2. Identify the opioids used for PCA. 3. Identify the adverse effects of opioids. 4. Explain the nursing implications when caring for a patient receiving PCA. 5. Use terminology associated with the PCA infusion pump. 6. Explain the procedure for programming the PCA infusion pump. 7. Discuss the possible complications, contraindications and precautions associated with PCA. METHOD 1. Independent study read the policy and procedure and learning module 2. Complete self test 3. Inservice/Discussion by APS 4. Complete the Proficiency Standard Skills Checklist PREREQUISITES: To manage the care of a patient receiving PCA the RN is to have met the competency requirements as outlined in this learning module. The RN is required to be deemed competent in the Post Entry-Level Competency Direct IV Administration of Medication MM and knowledgeable in the IV direct administration of Naloxone. Patient Controlled Analgesia CC Page 3 of 11

4 THEORY Patient Controlled Analgesia There are significant variations in analgesic requirements between individuals. The programming flexibility of PCA allows the physician to prescribe a customized pain management program for each patient. PCA allows a patient to self-administer intravenous analgesia via the prescribed program. Many patients who use PCA report greater satisfaction than patients treated with conventional as needed opioids alone. (Hudcova McNicol, Quah, Lau and Carr, 2009) Indications for PCA PCA therapy is suitable for patients undergoing procedures in which moderate to severe pain is anticipated, and where parenteral opioid administration will be indicated. When considering a patient for PCA, the patient must be able to understand PCA instructions and physically able to push a button on the PCA infusion pump. Role of the Acute Pain Service While patients are receiving PCA therapy, the APS will provide pre-printed physician orders for all analgesia including non-opioid analgesics such as NSAIDs and acetaminophen. The APS PCA pre-printed physician orders also address treatment for opioid side effects. While a patient is under the care of the APS, staff nurses must not administer other analgesics, sedatives or NSAIDS that have not been ordered or approved by APS. When the PCA pump is discontinued, the APS will sign off and ongoing postoperative pain management will be ordered by the attending service. Patient Education: Patients are educated in Post Anesthetic Care Unit (PACU) when PCA is initiated but require reinforced on the nursing unit. Patient teaching should include that PCA is intended for patient use only, how often the patient may press the PCA button, and recommendations to medicate prior to known painful activities. There is a Capital Health patient teaching pamphlet available for patients receiving PCA. It is important to determine whether the patient feels comfortable with selfadministration of opioids for post-op pain control. If for any reason a patient is having difficulty obtaining adequate pain relief from the PCA, the nurse should contact the APS. DRUG INFORMATION Drug Compatibility and Adverse Effects The RN responsible for the patient receiving PCA must check IV compatibility for current compatibility information when IV solutions and medications are piggybacked with the PCA IV line. Patient Controlled Analgesia CC Page 4 of 11

5 Commonly used PCA opioids and settings The following chart outlines the PCA medications used, drug concentrations, usual PCA doses, and lockout intervals. Drug Concentration PCA Dose Lockout Interval Hydromorphone 1mg/mL 0.1mg - 0.4mg 5-11 minutes Morphine 5mg/ml 1-2 mg 5-11 minutes Fentanyl 50mcg/mL 15-20mcg 5-11 minutes Medications used to treat side effects Medications listed below are commonly prescribed to relieve opioid side effects. DRUG USED FOR DOSE COMMENTS DimenhyDRINATE Nausea and vomiting mg IV q4h prn Antiemetic May cause drowsiness Ondansetron Nausea and vomiting 4mg IV q4h prn antiemetic DiphenhydrAMINE Treatment of pruritus mg IV q6h prn. Opiate antagonist. Naloxone Used for reversal of 0.4-2mg IVdirect QEII opioid induced respiratory 0.1-2mg mg IV direct depression. DGH May cause drowsiness Doses may be repeated Multimodal Multimodal analgesia produces optimal pain relief by targeting pain at multiple pathways. Combining analgesic techniques and drugs have a synergistic effect. Since opioids and non-opioid analgesics relieve pain by different mechanisms, non-opioid adjuvant medications such as non-steroidal anti-inflammatory drugs (NSAIDS) and acetaminophen are often prescribed as regular doses in addition to PCA opioids. The combination of opioids and non-opioids provides a multimodal approach to analgesia and has an opioid dose sparing effect (Vadivelu, Mitra and Narayan et al 2010) Patient Controlled Analgesia CC Page 5 of 11

6 Common non-opioid and adjuvant analgesic medications prescribed for acute pain management are listed below. DRUG USED FOR DOSE COMMENTS Acetaminophen Adjunct pain control 650mg 975mg po/pr q6h Acetaminophen dosing not to exceed 4000mg/24h Diclofenac Adjunct pain control mg pr/po q8-12h NSAIDs - contraindicated for pts Naproxen po/pr q12h with peptic ulcer disease, renal Ketorolac mg IV q6h insufficiency, bleeding disorders and allergies to NSAIDs or ASA. Celecoxib Maximum 400mg/24 hours Gabapentin Adjunct mg Dose can be titrated up Ketamine Adjunct for pain control for opioid tolerant patients mg/hour Clinical Practice Guideline MM NURSING IMPLICATIONS Patient Assessment The RN will assess the effectiveness of PCA therapy during each shift to ensure the patient has received satisfactory analgesia with minimal side effects. While a patient is receiving PCA therapy, the RN must assess and document the level of pain, the level of sedation, the respiratory rate and the PCA dose administered q2h x 24h then q4h. For opioid tolerant patients a continuous opioid infusion may be added or the patient may be ordered a long acting opioid to deliver the equivalent of the patient s 24 hour daily opioid dose. When a patient is on a continuous opioid infusion nursing assessments are often required hourly. Pain Level The patient s self-report is the most reliable indicator of pain intensity and should be used whenever the patient can provide it. Pain intensity can be measured using the 0-10 numeric rating scale, where 0 is no pain and 10 is the worst pain ever. Pain should be assessed both at rest and with function (i.e., coughing, movement). It is also important that you ask the patient if the pain is manageable. The goal of acute pain management is to manage dynamic pain (pain on movement) so the patient can deep breathe, cough and mobilize effectively (Breivik et al., 2008). Patient Controlled Analgesia CC Page 6 of 11

7 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 to reverse the depressant effect of the opioid. Therefore, monitoring sedation is the key to preventing opioid induced respiratory depression (Pasero and McCaffery, 2002). Risk factors for respiratory depression with intravenous PCA include a continuous background infusion, advanced age, use of CNS depressants, renal, hepatic or cardiac impairment, sleep apnea (suspected or history) and obesity. The goal in acute pain management is to balance analgesia with a level of alertness that allows the patient to perform activities that promote early recovery. The RN will assess sedation level by using the following somnolence score. 1 = awake and alert 2 = sedated but arousable 3 = requires vigorous stimulation to arouse 4 = unresponsive SL = normal sleep Patient Controlled Analgesia CC Page 7 of 11

8 Self -Test: Patient Controlled Analgesia 1. The minimum time interval that must pass after a PCA bolus dose is administered before another PCA dose can be delivered is known as: a) 4 hour dose limit b) PCA dose c) Lockout interval d) Loading dose 2. When is it necessary for two RN s to check the PCA settings? a) At the beginning of each shift b) When PCA is initiated c) When PCA settings are changed d) When the PCA cassette is changed 1) b, c 2) a, b, c 3) a, b, c, d 3. It is OK for the nurse to press the PCA button for the patient in certain situations. Circle True or False 4. When nonopioid analgesic medications are combined with opioids, known as multimodal analgesia: a) The opioid dose should be reduced b) The patient will experience increased sedation c) Produces optimal pain relief by targeting pain at multiple pathways d) Should not be done with elderly patients 5. If your patient requires vigorous stimulation to arouse, the somnolence score would be documented as: a) 1 b) 2 c) 3 d) SL 6. Your patient s PCA pump is alarming occlusion. The slider clamp is closed. Which one of the following actions would be most appropriate in this situation? a) Open the side clamp b) Disconnect the PCA tubing from the IV site and purge the IV tubing c) Relieve back pressure in IV line by squeezing and releasing cradle release handles d) Prime new IV tubing on the PCA cassette, purge and reconnect Patient Controlled Analgesia CC Page 8 of 11

9 7. Your patient, Mr. Smith, 45, is postoperative day 1 for an abdominal colectomy. Mr. Smith is receiving PCA morphine with a PCA dose of 2mg, lockout interval 5 minutes. Mr. Smith is rating his pain as 8/10 on a 0-10 pain scale and is refusing to get out of bed due to unrelieved pain. Describe appropriate nursing actions? Patient Controlled Analgesia CC Page 9 of 11

10 ANSWERS FOR PATIENT CONTROLLED ANALGESIA TEST 1. c False 4. c 5. c 6. c 7. Check history button on PCA pump to determine last hour and 24 hour opioid consumption Assess if Mr. Smith is using the PCA device appropriately Ask Mr. Smith if he was taking opioids in the preoperative period? If yes, find out which opioid was used, how much was taken and for what period of time If Mr. Smith appears to be using PCA appropriately and wishes to continue with the device, then notify the physician to discuss the patient s pain score and report of unrelieved pain. Discuss adding adjuvant medications with physician Educate Mr. Smith on effective use of PCA, (i.e., press the PCA button when pain first starts, before coughing and before mobilizing). You may also want to provide Mr. Smith with a PCA patient teaching pamphlet in order to reinforce what you have discussed with him Reassess Mr. Smith s pain within one hour Patient Controlled Analgesia CC Page 10 of 11

11 Capital District Health Authority Proficiency Standard Skills Checklist The RN verbalizes/demonstrates Checks APS physician orders Yes No Assesses pain score at rest and with function, somnolence score, respiratory rate and adverse effects Confirms PCA pump settings: CCA, PCA drug, PCA dose, lockout interval, continuous infusion rate (if ordered) Verbalizes when checks are required by two RN s Verbalizes interventions for side effect management Verbalizes how to contact APS if required Documents on the PCA flow sheet Patient Controlled Analgesia CC Page 11 of 11