One of the things I did for homework this week was read up on Patient Controlled Analgesia (PCA) devices, as used by our patient in our subject patient enquiry. I'm going to share this research with the rest of my group today. It 's also one of the nursing skills we've been introduced to in labs recently. This info gives a good run down of the basic aspects of this system: principles and advantages, how they work, features of the device, patient education, monitoring and other nursing duties surrounding using PCAs.
Reference:
Nicol, Bavin, Bedford-Turner, Cronin and Rawlings-Anderson [2004]. Essential Nursing Skills 2nd Edition. Mosby.
Patient Controlled Analgesia (PCA)
Principles and Advantages of PCA
Patient-controlled analgesia (PCA) has become a popular method of managing post-operative pain since the early 1990s. However, today its use is not confined to post-operative pain management. It has also been found useful in patients with burns, myocardial infarction, bone marrow transplantation, sickle cell crisis and terminal illnesses.
PCA facilitates active involvement of patients in the management of their pain. Through the use of a syringe driver and a timing device, PCA allows patients to self-administer small doses of an analgesic whenever they feel pain. It has several advantages over intermittent intramuscular or subcutaneous administration of analgesics on a PRN basis, which are:
1. PCA gives the patient a sense of control and there is no questioning of the validity of the pain.
2. It enables analgesia requirement to be individualised to a sufficiently high plasma concentration level and stable plasma concentration levels to be maintained thereafter. This prevents the peaks and troughs associated with intermittent injection.
3. Unlike the conventional system of intermittent injection, the is no delay between the request for analgesia and the provision of pain relief.
4. It saves nurses’ time.
How PCA devices work
PCA is usually administered intravenously (although epidural and subcutaneous infusions are sometimes used) via a syringe driver and time device. The patient activates the system by pressing a button that releases a small dose of the analgesic into the circulation. There is a lock-out device that prevents further doses being delivered with a specified time interval (usually between 5 and 20 minutes depending on the drug and dosage). The use of the lock-out device reduces the risk of overdose. Morphine is the most common opiate used and a dose of 1mg at 10 minute intervals will usually provide effective pain relief with minimal side effects provided the patient is carefully monitored throughout.
Features of PCA Devices
There is a variety of battery or electrically operated PCA devices available. Most include the following features:
• A facility that prevents the device delivering more than the maximum preset dose of a set period , eg 4 hours.
• Safety features that include alarms for occlusion (blockage), air in the line, low battery or empty syringe.
• A keypad lock and other locking devices that prevent unauthorised access and changes to the programme.
• An electronic microprocessor that allows the flow rate, bolus dose and lock-out interval be set. This will usually record the number of bolus doses and requested and administered, which is important when determining the effectiveness of the PCA.
Patient Education
Patient education regarding the use of PCA is vital and with surgical patients it should occur pre-operatively. The patient should be encouraged to handle the device and press the buttons etc in order to become familiar with the device and using it. It is important that the nurse notes the patient’s understanding and dexterity in handling the equipment because patients who are unable to manage the device may not receive analgesia and suffer as a result. If a patient is unable to use the system, nurse-administered analgesia will be required.
Monitoring the Patient and other Nursing Roles
Regular monitoring is essential for patients with a PCA. This includes:
1. Close monitoring of respiration rate, particularly immediately after commencement, as respiratory depression is the main side effect of opiate analgesia. Local hospital protocol should be consulted regarding the action to be taken if respirations fall below a certain level. A respiratory rate of between 8 and 10 respirations a minute usually requires intervention from the pain control nurse, the anaesthetist or doctor. Some protocols stipulate that patients should have oxygen administered while the PCA is in progress. Oxygen saturation levels should be recorded with the respiratory rate.
2. The patient’s blood pressure, pulse and sedation level should be monitored and recorded.
3. Pain should be assessed using a pain assessment tool/scale to ensure effective pain relief is being achieved.
4. The incidence and severity of any nausea and vomiting should be recorded.
5. Where possible, patients’ usage (ie how often they press the button) should be monitored to determine whether the pain control is effective.
6. The prescribed settings for the PCA system should be checked regularly to ensure proper functioning.
7. All of the above should be monitored at least hourly in the early stages.
8. The nurse should also monitor the infusion site for signs of inflammation, redness or tissue damage.
9. As with all controlled drugs, the nurse should prepare, administer and document the infusion in accordance with government policy.
10. The nurse should ensure no other opiates are administered whilst the patient is receiving PCA.
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