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PCA & EPIDURAL ADMINISTRATION

RNURS-033

Required Reading
Skill 13.3: Patient-Controlled Analgesia
13.1: Epidural Analgesia

Objectives
In the classroom, clinical, and/or lab the student will:
Describe how PCA and epidural analgesics are administered and the
advantages and disadvantages of each.
Interpret orders and understand equipment to insure the correct dosage of
medication is administered.
Assess the client for pain control and side effects of medication.
Teach the client:
to assess own pain
how/when to use PCA
pain level management
of right to pain control
Document assessment, pain control, medication administered and any side
effects.

Why PCA & Epidural?
Research shows:
Better pain control
Earlier client ambulation
Higher client satisfaction

PCA:
Definition:
Uses:
Good Candidates:
Poor Candidates:


Commonly used medications:

Route:
Primarily IV, epidural, and SQ
Transdermal
Variations:

PCA Advantages:
More constant serum levels of opioid
Reduced opioid used when client controls when medication administered
Better pain relief
Fewer side effects from opiods
Decreased complications d/t earlier & easier ambulation
Eliminates need for IM analgesics
Allows client to sleep at night while minimizing daytime drowsiness
Allows for client independence

PCA Disadvantages:
Client Related Issues:

Pump Failure:

Operator Related Issues:

Key: careful, ongoing management
Assessments:
Check MD order
Client Allergies
Clients cognitive ability
Clients physical ability
Pain (PQRSTU)
Environment for factors that increase pain
Existing IV infusion line
Presence of Sleep Apnea
Check PCA Infusion Pump Settings at start of Shift by pressing HX Button=>
compare to MD order

Planning:
Expected Outcomes

Delegation Considerations

Narcan
Know dose; dilution; timing

Narcan
Mix 0.4 mg/ml (1 ml amp) in 9 ml of NS (10 ml total volume)
Administer 1 ml of diluted Narcan (0.04 mg/ml) IV stat
Give 1 ml diluted Narcan IV q30-60 sec up to a total of 20 ml (total Narcan dose
0.8 mg/2amps) until sedation level is 2 or respiratory rate is >10/min

Interpretation of MD Order
Loading Dose
Basal Infusion Rate
PCA Dose
Bolus Dose Administered by RN
1-4 Hour Dose Limit
Lockout Interval

Implementation: See Text
Client Education:
Medication
Purpose and Benefits
Side Effects and When to Notify RN
Goal for Pain Control
Demonstrate function of PCA
Lock-out and inability to Overdose
When to use PCA


Attach PCA pump to pole less than 10 inches above infusion site
Attach med syringe and Prime PCA tubing with Morphine or Dilaudid
Prime Primary IV line with NS and insert into IV pump
Connect tubing from PCA pump to Primary Line at Y site closest to patient
Set pump according to MD orders
2 RNs must Independently verify medication, dose & rate & cosign MAR
Medication
Basal infusion rate
PCA dose
1-4 hour lock-out
Lock-out interval
Must re-verify: q8hr; new med syringe, pump setting change

Changing Medication Syringe
Check MD orders
Obtain correct med syringe
Raise top bracket-remove old syringe
Uncap new syringe-place in chamber & slide down bracket
If changing to new medication => change tubing also

Assessment &
Documentation
15 min post Q 2 hr
& prn
Q4 hr
& prn
Q8 hr
RR
O
2
Saturation
Sedation Level
Concentration
Rate
Pump

1
st
24
hr

After 1
st

24 hr

Pain Intensity Administration of
supplemental
narcotics or
sedatives
IV site for s/s of
infection/infiltration

Medication &
Concentration
PCA Dose
Basal rate
1-4 hr Dose Limit
Lock-Out Interval
# of injections
# of attempts
Total narcotic
administered

(Pump
settings
only)


Sedation Scale
S = asleep
1 = Awake and alert
Action needed:
2 = Slightly drowsy
Action needed:
3 = Frequently drowsy, drifts off during conversation
Action needed:
4 = Somnolent, minimal or no response to physical stimulation
Action needed:

Actions for Sedation Level 3 @ JMCC
DC Continuous/Bolus rate if present
Decrease PCA dose by 50% if no Continuous/Bolus rate
Begin Respiratory Risk Precautions
Notify MD

Respiratory Risk Precautions
Check RR, SpO2, sedation level q 1 hr until scale 2
Call MD if SpO2 <92% & RR <8 and immediately give or increase O2 to max of
6L/min via NC to maintain SpO2>92%
If insufficient,
OxyMask or Non-Rebreather at 8-15 L/min
Notify RT
Notify Rapid Response Team
Notify MD

PCA ADMINISTRATION
Miscellaneous:
Meperidine (Demerol) NOT recommended for PCA
No additional IV/IM/PO narcotics are to be given unless ordered by MD initiating
PCA
Primary Infusion:
Currently infusing compatible fluid @ current rate or
D
5
NS @ 30 ml/hr

Other Meds
Commonly Ordered with PCA
Ondansetron (Zofran) prn nausea
Dephenhydramine (Benadryl) prn itching
Notify MD if itching unrelieved
Docusate sodium (Colace) PO daily
Hold for loose stools
Bisacodyl (Dulcolax) PO daily
Hold for loose stools


What do you do if client pain continues or worsens?



What do you do when the MD orders PCA to be Discontinued?



Even with the lock out factor clients can be overmedicated? Why?


What can you do when the client is overmedicated?



Should PCA be used to treat acute pain in addicted patients?



PCA: Pediatric & Geriatric Considerations
Pediatric:
Age 8-9
Understand concept
Geriatric:
Sensitive to analgesic properties an side effects of opioids
Slow opioid metabolism & excretion
Start low and go slow
What if becomes confused while taking?
EPIDURAL ADMINISTRATION
Definition:

Uses:


Eligible Clients:


Commonly Used Medications:
Opioids; local anesthetics; separately or in combination
Route: Epidural
Patient Controlled?

How does it work?
Analgesic is distributed via:
Diffusion through dura mater into CSF
Blood vessels in epidural space transport systemically
Absorption by fat in epidural space creating a depot for slow systemic
release
Analgesic acts by binding to opiate receptors in the dorsal horn of the spinal cord
blocking pain impulse transmission to cerebral cortex

Figure 13-4 Anatomical drawing of epidural space.

Epidural Space:
Space found just outside the dura mater, which is the outermost membrane
covering the spinal cord. There is no direct contact with cerebral spinal fluid in
the epidural space.

Figure 13-5 Placement of epidural catheter.

Advantages of Epidural Administration:
Lower total dose of opioid required to control pain d/t delivery close to site of action
(CNS)
Lower doses of opiods => fewer side effects
Client can ambulate earlier
Client less drowsy

EPIDURAL ADMINISTRATION
Pain Medication ordered by anesthesiologist ONLY
No other narcotics/sedatives except those ordered by anesthesiologist
Deliver MD ordered medication boluses by pump only

Disadvantages of Epidural Administration
Potential for respiratory depression
Potential for catheter migration into subarachnoid space resulting in dangerously
high levels of medication
Urinary retention
Respiratory depression
Motor or sensory changes d/t effect of analgesia on spinal cord transmission below
the level of catheter insertion
Requires frequent monitoring

Clients at Increased Risk for Respiratory Depression Include Those:
Greater than 70 years of age
Receiving concurrent CNS depressants
With renal, hepatic, and/or cardiac impairment
With pulmonary impairment such as sleep apnea, increased intracranial pressure,
COPD, asthma
With upper abdominal or thoracic surgery
With obesity

Respiratory Risk Precautions
Follow those on earlier slide

Common Medications Used
Opioids:
Morphine
Hydromorphone
Fentanyl
Sufentanil

Baseline Assessment
Check MD Order
Client Pain (PQRSTU)
Drug Allergies
Sedation level
Respiratory rate; pattern: depth
BP
Initial motor/sensory function
Insertion site; tubing (patent; secured)
Contraindications:
Use of anticoagulants; herbal meds; abnormal clotting studies; hx of multiple
abscesses; sepsis; skeletal or spinal abnormalities

Planning
Expected Outcomes


Delegation Considerations


Implementation
EQUIPMENT
Medication clearly labeled
Independent Verification: confirm medication, dose & pump settings with another
RN, initially and with any change in rate. 2nd RN cosigns MAR
Pump labeled Epidural ONLY
Tubing with no Y-ports
Pump settings
Dressing change & line removal by anesthesiologist only.
RN may reinforce dressing prn

Assessment/
Documentation
Contin-
uous
15 min. Post q1 hr
& prn
Q2hr
& prn
Q8 hr
&prn
SpO2
Until 12
hr p DC

Pain intensity
Sedation level
RR
SpO2
Concentration
Rate
Pump
1
st
24
hr
Until
12 hr
p DC

Catheter
insertion site
Motor/ sensory
function/CMST
of lower
extremities
BP; pulse
Temp

Med
Concentration
Diluent
Dose/Pump
Setting
Total narcotic
administered




Ongoing Assessment & Documentation
Side Effects:
Urinary retention/constipation
Is/Os; bladder distention
Nausea
Vomiting
Pruritis
Headache

Ongoing Assessment and Documentation

EPIDURAL ADMINISTRATION
Miscellaneous:
Have oxygen equipment, bag/valve/mask, & Narcan available to treat respiratory
depression
Patient located near nursing station for frequent assessment
Check orthostatic BP prior to ambulating for first 24 hr

When to call anesthesiologist
Changes in CMST
Confusion
Continued dizziness
Nausea
Increased heart rate or lightheadedness present with decrease in BP
Any problems with epidural line including catheter leak, disconnection, redness or
drainage at insertion site

Unexpected Outcomes
See Text
What to do if catheter becomes disconnected, or sterility is compromised?

Epidural: Pediatric & Geriatric Considerations
Pediatric
OK all age groups
Dosed per kg
Requires: Continuous cardiac, respiratory, O2 sat monitoring
Geriatric
Beware hypotension esp. in those taking antihypertensives

PCA & EPIDURAL ADMINISTRATION
Review:
Provide acute pain control
Administer correct medication dosage
Interpret orders
Know the equipment
Assess patient for pain and side effects
Teach patient
Documentation