Patient Controlled Analgesia

(PCA)

Learning Guide

for Enrolled Nurses (Medication Endorsed)

MAH, MPH, MMH, MPHR

Adapted from the RN PCA Learning Guide and Competencyby:

Cassandra Thompson Acting CNC Acute Pain Management

Mater Health Services

December 2010

Reviewed by:

Leanne Gleeson CNC Acute Pain Management

Acknowledgement:

Helen Stewart

Mater Misericordiae Health Services Brisbane Limited

Our
Mission
“In the spirit of the Sisters of Mercy, the Mater Hospital offers compassionate service to the sick and needy, promote an holistic approach to health care in response to changing community needs and foster high standards in health related education and research. Following the example of Christ the Healer, we commit ourselves to offering these services to all without discrimination.”
Our
Values
/ Care:The spirit of compassion
/ Mercy:The spirit of responding to one another
/ Dignity:The spirit of humanity, respecting the worth of each person
/ Quality:The spirit of professionalism
/ Commitment:The spirit of integrity

Patient Controlled Analgesia for EN (Med)

INDEX

Aims / 2
Resources / 2
Competency / 2
EEN scope of practice – PCA’s / 3
What is pain? / 4
Pain assessment / 5
Functional Activity Score (FAS) / 6
Adverse effects of unrelieved pain / 7
Barriers to effective pain relief / 7
Optimising analgesia / 8
The role of patient controlled analgesia (PCA) / 8
Patient education / 8
Complications / 9
Management of opioid related side effects / 9, 10, 11
PCA program check / 11
PCA observations / 12
PCA settings / 12
Naloxone / 13
Questions / 14, 15
References / 16
Competency form / 17

AIMS

The aim of this guide is to:

  • gain knowledge regarding Patient Controlled Analgesia
  • maximise safety and efficiency in the use of the PCA
  • increase understanding, knowledge and confidence amongst nursing staff in the use of pain pumps
  • increase understanding and knowledge of acute pain management.

RESOURCES

In addition to this learning guide the following resources are available:

  • CNC’S Acute Pain Management (Speed Dial: 77161 or 77139)
  • Clinical Facilitator or Nurse Educator
  • Clinical Nurse
  • “Alaris” (IVAC PCAM) Clinical Nurse Educator (Ph:0437 863 412)
  • “Hospira” (Gemstar) Clinical Nurse Educator (Ph: 0401 674 394)
  • Mater Education Centre website/ Nursing Learning Resources/ Useful Resources:
  1. “Omnifuse” PCA Pump
  2. “Gemstar” PCA Pump
  3. “Alaris” PCAM Pump

HOW TO ATTAIN COMPETENCY

  • Read this learning guide
  • Read the Mater Health Services PCA policy available from Docu-Cube
  • Complete the multiple choice questions of this learning guide
  • Ask a clinical assessor/nurse educator to mark your exam
  • Download the appropriate PCA clinical competency for your work area fromthe Mater Education Intranet site as follows:

1. “Omnifuse” PCA Pump & “Grasby 3300” - MPH

2. “Gemstar” PCA Pump - MAH

3. “Alaris” PCAM Pump - MMH

  • Practice this competency in your clinical area
  • Complete the competency under supervision of an appropriate assessor
  • Send your completed competency to the Mater Education Centre for entry into MOVES.

HOW TO MAINTAIN COMPETENCY

  • Annual competency is strongly recommended for nurses/midwives who infrequently care for patient’s with PCA
  • For nurses/midwives who consistently care for patients with PCA’s it is strongly recommended competency should be performed every 2years

Enrolled Nurse (Med) specific scope of practice

  • Prior to caring for a patient with a PCA infusion, the Enrolled Nurse (Med) must possess knowledge of the indications, usual dose, safe administration and signs of adverse effects of any drug being administered by the PCA
  • The Enrolled Nurse (Med) may check the drawing up of the PCA and the programming with an RN
  • The Enrolled Nurse (Med) can independently check the machine programming against the orders with an RN
  • The Enrolled Nurse (Med) can check the PCA machine is operating correctly, and reports concerns to the supervising RN
  • It is vital to inform an RN immediately if the patient is experiencing any adverse effects or if assistance is required.
PAIN

What is pain?

There are two broad categories of pain: acute and chronic. Acute or nociceptive pain is defined as pain of limited duration that is related to a specific event or illness (Mann & Carr, 2006). It usually has an identifiable cause and is related to underlying disease or injury. Acute pain is a protective mechanism which serves to warn the individual that ‘something is wrong’ and to seek help. In this way it is seen as a warning sign e.g. appendicitis. Once the underlying mechanism has been identified and treated, pain should decrease as healing occurs.

Chronic pain is considered as pain without apparent biological value that has persisted beyond the normal tissue healing time (MacLellan, 2006). It is linked with maladaptive behaviour and responses which have adverse psychological consequences. Persistent (chronic) pain does not have a predictable endpoint. It may occur as a result of an acute injury and it does not have a purpose e.g. chronic back pain, phantom limb pain. Some acute pain states that might progress to persistent pain include post traumatic pain, mastectomy and acute back pain. There is some evidence to suggest that early analgesic intervention after surgery decreases the risk of persistent pain (NHMRC, 2005).

Patients affected by persistent pain may be withdrawn and depressed and may have reduced activity levels. Patients with persistent pain are frequently under treated because healthcare providers fail to recognise that their pain is significant. It is essential healthcare providers recognise, acknowledge and treat persistent pain to improve compliance with management goals and patient outcome.A multidisciplinary treatment approach for chronic pain that focuses on self-management and restoration of function is the goal of therapy (Turk & McCarberg, 2005).

Another type of pain which may be associated with acute or chronic is neuropathic pain. Neuropathic pain occurs as a result of damage, disease or injury to the central or peripheral nervous system. The mechanism and treatment of neuropathic pain differs significantly from acute nociceptive pain therefore recognition in its early stages and initiation of appropriate therapy is essential to prevent ongoing sequelae (ANZCA, 2005).

Factors Affecting Pain

Pain is an individual experience which will be influenced by many factors including the patients knowledge of pain and analgesia, their expectations of pain, past experiences, fear of addiction, anxiety, culture, age, lack of information and the influence of healthcare professionals responsible for their care. The cause of an individual’s pain will relate to the degree of tissue damage however the context of that pain will shape the experience and ongoing management (MaClellan, 2006).

The patient’s memory of previous pain experiences influences pain perception. Previous negative experiences increases fear and anxiety which is associated with a heightened awareness of pain.

The emotional response to pain will depend on the meaning of pain to the individual. Anxiety and depression arepredisposing factors which can impact on a patient’s response to pain. Anxiety is often associated with pain because of underlying concerns or fears about disease or disability.

Pain Assessment

Subjective Information

The patient’s report of pain is the most reliable indicator of pain severity (ANZCA, 2005). Pain assessment includes:

  • Intensity at rest and on movement
  • Type (description)
  • Location
  • Onset
  • Duration
  • History of previous pain

Pain Intensity

Pain intensity is assessed by asking patients to rate their pain on a scale of 0 to 10 where 0 represents ‘no pain’ and 10 represent ‘worst pain imaginable’. Measurement of pain intensity includes asking how much pain the patient has while at rest and if pain interferes with sleep. Pain assessment on ‘movement’ and its impact on function is also determined.

Pain assessment should occur:

  • on admission as the 5th vital sign and with routine observations
  • before, during and after administration of analgesics
  • as per PCA or Epidural/Regional Infusion Standing Orders if the patient is receiving this method of analgesic therapy

Types of Pain

It is essential when performing a pain assessment to ask the patient to describe the pain they’re experiencing.

Neuropathic or ‘nerve’ pain is associated with nerve injury or disease of the spinal cord or peripheral nerves. Nerve injury results in the following signs and symptoms:

  • Pins & needles
  • Hot or cold or burning
  • Episodic shooting pain
  • Squeezing
  • Electric shock

Further indicators of neuropathic pain are:

  • Allodynia (non painful stimulus is painful e.g. light touch)
  • Changes in colour, temperature and sweating in the affected or opposite limb.

Some surgical procedures have a higher risk of developing neuropathic pain. Two of the most common are thoracotomy and mastectomy. Neuropathic pain may also occur as a result of burn injuries.

Phantom Pain

Phantom pain is a form of neuropathic pain that occurs after amputation and is pain which is experienced in the body part that has been amputated e.g. foot, breast. This occurs because the brain is still receiving messages from the damaged nerves. Not all patients with amputation will experience phantom pain however it is most likely to occur in patients who have had traumatic amputations (e.g. caused by an accident) or those with significant pre-operative pain over a long period of time (ANZCA, 2005).

*Referred pain is pain that is distant from the site of origin or adjacent to it e .g. heart pain is often referred to the arms.

Location of Pain

It is important to identify the location of pain to assist with determining what type of analgesic is required. Pain may be located in one or more areas of the body or it may be radiating from one area to another. In some instances pain may be long standing e.g. arthritis, therefore the pain medication prescribed for acute pain may not appropriately treat the pain that the patient is referring to.

Pain History

Determine the duration of the pain and what makes it better or worse. Is it continuous or intermittent? Has the patient experienced this type of pain before and if so what relieved it? What makes the pain worse e.g. exercise and when does the pain occur e.g. after meals? Ask the patient about different types of pain they might commonly experience e.g headaches.

Objective Information – Functional Activity Score

Physiotherapy, activity and rehabilitation are an important phase of a patient’s recovery and sense of well being. Strong pain relief is often required to assist the patient through this phase.To determine if pain impacts on function the functional activity score (FAS) is used. FAS is the midwife/nurses assessment of the patients pain and is therefore an objective measurement. This tool is used in MMH(refer to carepaths).

Functional Activity Score (FAS)

Does pain interfere with function?

A = does not interfere

B = partly interferes

C = completely interferes

Inadequate analgesia is an adverse event.

In MAH pain scores ≥ 4

In MMHpain scores ≥ 4or (FAS=C)

In MPH’s pain score ≥ 4

Require further assessment by the EEN/RN.Encourage PCA bolus.

If pain is unrelieved contact APS MAH speed dial 6647, APSMMH speed dial 6616, or contact MO for private patient’s.

Adverse Effects of Unrelieved Acute Pain

Cardiovascular / Tachycardia, hypertension, increased peripheral vascular resistance, increased myocardial oxygen consumption, myocardial ischaemia, altered regional blood flow, DVT, pulmonary embolism
Respiratory / Reduced lung volume, atelectasis, decreased cough, sputum retention, infection, hypoxemia
Gastrointestinal / Decreased gastric and bowel activity
Genitourinary / Urinary retention
Neuroendocrine/Metabolic / Increased catabolic hormones e.g. glucagon, vasopressin, renin, angiotensin
Decreased anabolic hormones e.g. insulin, testosterone
Catabolic state leads to hyperglycaemia, increased protein breakdown, impaired wound healing and muscle wasting leading to increased pain
Central Nervous System / Chronic (persistent) pain due to central sensitization

Adapted from MacIntyre & Schug, 2007.

Barriers to Effective Pain Relief

Under treatment of severe acute pain coupled with the physiological response to surgery, can have a number of effects and may lead to complications such as myocardial ischaemia, infarction or pneumonia. Unrelieved acute pain may also lead to chronic persistent pain. Knowledge and resources exist to provide adequate and safe analgesia to the majority of the population who suffer pain, however numerous studies indicate that approximately 50% of the population still experience severe pain after surgery (MacIntyre & Schug, 2007).

Possible barriers to effective pain relief include:

A belief that pain is not harmful

Concerns that pain relief will obscure a diagnosis or mask signs of a surgical complication

A tendency to underestimate a patient’s pain

Lack of recognition by clinicians of the variability in patients pain perception

Lack of regular and frequent assessment

Fears that patients will become addicted to opioids

Concerns about a high risk of respiratory depression with opioids

Inadequate patient education

Patient reluctance to ask for analgesia

Lack of understanding of inter-patient variability in opioid requirements

Lack of recognition that age is a better predictor of opioid requirement than weight in the adult patient

Prolonged dosage intervals

Insufficient flexibility in dosing schedules

Lack of understanding of the need to titrate analgesics to meet the needs of the patient

Lack of accountability for pain management

Optimising Analgesia

Under treatment of pain can lead to increased patient anxiety and stress. Pain management involves controlling pain before it becomes established. Ways in which to optimise a patient’s analgesia include:

Pre-emptive analgesia, e.g. before moving, deep breathing. Allow time for the analgesia to take effect

Treat side effects early and adequately

Adjunctive analgesia e.g. NSAID’s, may be required

Patient’s should not be sedated

Believe the patient’s pain assessment

Act on the assessment

The Role of Patient Controlled Analgesia (PCA)

PCA refers to a mode of analgesia that allows a patient to self administer small and frequent doses of opioid as required. PCA is administered via a programmable infusion pump that delivers medication intravenously. Compared to conventional modalities of pain relief (IMI, SC or IV), PCA offers greater patient satisfaction without increasing the incidence of opioid-related side effects (MacIntyre & Schug, 2007).

PCA overcomes the wide variability in opioid requirements between individual patients (between 8 to 10 fold). The intensity of acute pain is rarely constanttherefore when using a PCA, the individual is able to titrate their analgesia according to their level of pain. In this way patients are more likely to maintain their opioid serum concentrations within a therapeutic range (analgesic corridor).

Patient Selection

A number of factors have to be considered when selecting a patient for PCA. Great care must be taken to ensure that this form of modality is appropriate (McCaffery & Pasero, 1999). The use of PCA is contraindicated in the following category of patients:

Patient’s with cognitive impairment who are unable to understand how to use the machine

Non-English speaking patients unless an interpreter is available to explain how to use the machine

Patient’s with a physical disability or those who have limited manual dexterity to press the button themselves

Patients who don’t wish to manage their own analgesia

Pre-operative dementia

Post-operative confusion

NB: Difficulty understanding or inability to manage the technique, language barrier, confusion, or a physical disability that impedes use of the PCA button is a contraindication to PCA. Inform the APS/VMO if this applies to your patient.

Patient Education

With appropriate instruction, patients selected for PCA should be able to achieve a level of comfort to enable acute rehabilitation (effective cough and mobilisation). Patients must understand how to use PCA if they are to obtain safe and effective pain relief. Education should begin pre-operatively, whenever possible, followed by continuous reinforcement of the technique post-operatively.

Patient information required to assist understanding of PCA includes:

When the PCA button is pressed the pump is activated to deliver pain medication into the intravenous line

Possible side effects include nausea and vomiting, drowsiness, itch, difficulty passing urine, confusion, hallucinations, constipation

Only one dose can be delivered in any set period (e.g. 5mins), no matter how often the button is pushed

The PCA button is pushed to keep pain under control and before doing something which is likely to be painful e.g. physiotherapy

The medication doesn’t work immediately, allow 5-10 minutes for it to make a difference

Do not wait until pain becomes severe before pressing the PCA button

Complete pain relief may not be possible

Only the patient is to push the PCA button

Report any side effects or pain that is not controlled

The risk of addiction is minimal when used for acute pain

Complications of PCA

Complications associated with PCA may be related to the side effects of the drugs used, the equipment involved or management by staff or patients.

Opioid Related Side Effects

Opioid related side effects may occur regardless of the route of administration. Side effects include:

Sedation

Respiratory depression

Nausea and vomiting

Pruritus

Urine retention

Confusion

Decreased bowel activity/constipation

Hypotension

Management of Opioid Related Side Effects

Sedation

The most serious complication of excess opioid consumptionis respiratory depression: the best indication of impending respiratory depression is increasing sedation (MacIntyre & Schug, 2007).Sedation score is used to assess levels of consciousness according to the following tool:

Sedation Score

S = Sleep – rouses with light touch or mild stimulation

0 = Awake

1 = Mild – occasionally drowsy, easy to rouse

2 = Moderate – rouseable but not able to stay awake (eg. will wake easily, but tends to fall asleep during conversation); assess respiratory rate & refer to Naloxone policy

3 = Severe – difficult to rouse or unrouseable; refer to Naloxone policy

Sedation score = 2 and respiratory rate = 8 or greater

  1. Administer oxygen if not contraindicated
  2. RN to cease opioid/remove PCA button
  3. Monitor sedation score, respiratory rate and oxygen saturations every hour until sedation score less than 2.
  4. Contact APS:

Speed dial 6647 (MAH),