Perioperative Pharmacology: Patient-Controlled Analgesia

RODNEY W. HICKS, PhD, RN, FNP-BC, FAANP, FAAN; JOHNANNA HERNANDEZ, PhD, RN, FNP-BC; LINDA J. WANZER, MSN, RN, CNOR

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ABSTRACT
Patient-controlled analgesia (PCA) is an effective treatment option for reducing pain, but PCA errors can be quite serious. Opioid analgesics are among the most effective pain relievers available, but all have contraindications and can have adverse effects, including respiratory depression and other effects on the central nervous system. Practitioners must weigh the potential benets of PCA use against the risks. Errors associated with the PCA process have been documented in each phase of the medication-use process; therefore, practice improvements in prescribing, transcribing, dispensing, administering, and monitoring PCA may reduce the likelihood of errors. Perioperative nurses can make important contributions to safe PCA use by establishing standardized processes to help ensure positive patient outcomes in pain management. AORN J 95 (February 2012) 255-262. Published by Elsevier, Inc., on behalf of AORN, Inc. doi: 10.1016/j.aorn.2011.05.022 Key words: patient-controlled analgesia, medication safety, patient safety, opioids.

atient-controlled analgesia (PCA) is one approach to relieving postoperative pain.1 Using PCA allows each patient to titrate his or her own acceptable level of analgesia. Intravenous PCA involves use of an electronic infusion device (ie, a pump) that has volumetric regulating capabilities and a timing mechanism to allow the patient to self-administer IV analgesic medications.2
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire February 28, 2015.

Opioid analgesics (eg, morphine, hydromorphone, fentanyl, meperidine) are among the most effective pain relievers available.3 The entire IV PCA process, however, is complex and error prone.4 Risks and benets of opioid analgesics are well chronicled and beyond the scope of this article. The purpose of this article is to review the pharmacological properties of opioid analgesics, present data from medication errors associated with PCA use, and describe the roles and responsibilities of perioperative nurses during PCA use. Understanding the pharmacology of PCA agents, best practices in regard to PCA use, and standardization of processes across organizations can direct the actions of perioperative nurses and help patients attain optimal outcomes.
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TABLE 1. Location and Responses of Major Opioid Receptors1 Mu ( )1-3

Location

Kappa ( )1-3

Brain Cortex Thalamus Periaqueductal gray Striosomes Spinal cord Substantia gelatinosa Intestinal tract
1

Brain Hypothalamus Periaqueductal gray Claustrum Spinal cord Substantia gelatinosa

Response

1-3

Supraspinal analgesia Dependence Respiratory depression Miosis Euphoria Reduced gastrointestinal motility Dependence Unknown

Spinal analgesia Sedation Miosis Inhibition of antidiuretic hormone Dysphoria

1. Fine PG, Portenoy RK. The endogenous opioid systems. In: A Clinical Guide to Opioid Analgesia. Minneapolis, MN: McGraw-Hill; 2004:9-15.

PHARMACOLOGY OF OPIOID ANALGESICS Opioids exert strong analgesic effects (eg, the ability to relieve pain without causing loss of consciousness).3 As such, medications in this class act as agonists on the mu and kappa receptors in the central nervous system (CNS). Mu receptors are located in the brain, spinal cord, and intestinal tract. Kappa receptors are located in the brain and spinal cord (Table 1).5,6 These receptors are also responsible for other CNS effects such as euphoria or respiratory suppression.3,5 The slight differences in onset, peak, and duration of common opioids are presented in Table 2. Part of the differences rest in the individual products lipid solubility and the ability to cross the blood-brain barrier. Opioid metabolism is predominantly accomplished through the cytochrome P450 enzyme system. Therefore, inhibitors of this system (eg, macrolides, antifungal agents, protease inhibitors) can lead to prolongation of the medications effects and may result in serious adverse
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effects. Impairments of the hepatic system also may affect opioid metabolism. The renal system plays a smaller role in opioid clearance, and impairments of this system also affect plasma levels. Opioids belong to the schedule II class as outlined in the United States Code Controlled Substance Act7; therefore, organizations and facilities that use such products must comply with a

TABLE 2. Comparison of IV Opioids by Onset and Duration1 Agent

Morphine Hydromorphone Fentanyl Meperidine

Onset
20 minutes 10 to 15 minutes Immediate 1 minute

Duration
4 to 5 hours 2 to 3 hours 0.5 to 1 hour 2 to 4 hours

1. Lehne RA. Opioid (narcotic) analgesics, opioid antagonists, and nonopioid centrally acting analgesics. In: Study Guide for Pharmacology for Nursing Care. 7th ed. St Louis, MO: Saunders Elsevier; 2010:69-72.

PATIENT-CONTROLLED ANALGESIA host of documentation standards. Practitioners also follow other local, state, and federal standards to enforce practices that prevent product diversion. Safe disposal of unused products must comply with a host of local, state, and federal guidelines, and disposal should occur in a manner that protects municipal water supplies. Morphine Morphine is classied as a pregnancy category C medication and is the most commonly used IV PCA opioid. Pregnancy category C is dened by the US Food and Drug Administration as medication that has shown adverse effects on fetuses in animal studies; however, there are no wellcontrolled studies in humans. Practitioners must weigh the potential benets against the risks. Morphine has low protein binding ( 40%), and up to 12% of the unchanged product can be eliminated via urine. The half-life of morphine is between 1.5 and two hours.4,6 Practitioners should use the following parameters to achieve optimal analgesia when using morphine PCA for a patient who is opioid naive: 1-mg to 2-mg bolus, six-minute lock-out interval, and self-administration dose of 1.5 mg to 3 mg per hour.

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sants (eg, alcohol, sedatives). Morphine should not be used by pregnant women because it can cross the placental barrier and has been found in breast milk.4,6 The most serious adverse effects of morphine administration are respiratory in nature, leading to hypoventilation and hypercapnia. Other, lesscommon adverse effects include CNS depression, psychosis, constipation, euphoria, and oliguria. Rapid cessation of PCA can precipitate withdrawal symptoms in some patients.4,6 Hydromorphone Hydromorphone, also a pregnancy category C medication, is a pure opioid agonist used for analgesia. Approximately 1 mg to 2 mg of hydromorphone is equivalent to 10 mg of morphine. Hydromorphone has low protein binding ( 20%). The mean half-life of hydromorphone after IV administration is about 2.5 hours, and there is extensive tissue uptake. Hepatic impairment can increase the half-life fourfold, and renal impairment can affect clearance.4,6 For PCA use, hydromorphone may be ordered with a concentration of 0.2 mg/mL. The demand dose is commonly 0.1 mg to 0.2 mg, with a ve- to 15-minute lock-out interval. A four-hour limit may be set at between 4 mg and 6 mg.4,6 Absolute contraindication to hydromorphone use is known hypersensitivity. The perioperative nurse must exercise care when administering the product to patients who have respiratory depression or status asthmaticus because hypoxia can result. A relative contraindication is gastrointestinal obstruction because this product decreases peristalsis. Hydromorphone may mask symptoms of an acute abdomen. Therefore, the presence of biliary tract or pancreatic tract disorders may preclude its use.4,6 Adverse effects of hydromorphone include respiratory depression, hypotension, ushing, constipation, and urticaria. There are no indications for use by women who are in labor or are breastfeeding.4,6
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For opioid-tolerant patients, the order should include 1-mg to 3-mg bolus, six-minute lock-out interval, and self-administration dose of 3 mg to 10 mg per hour.4,6

An absolute contraindication to morphine use is the presence of a pre-existing allergy. Relative contraindications include acute asthma or signicant upper airway obstruction. The underlying pathology of biliary tract disorders is another contraindication because morphine may precipitate biliary colic. Routine use of morphine PCA in patients with head injuries is discouraged, as is the concomitant use of other CNS depres-

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HICKSHERNANDEZWANZER Concurrent use of meperidine and other CNS agents (eg, analgesics, antidepressants, alcohol, hypnotics) potentially can cause signicant serious interactions. Such interactions can include respiratory depression, hypotension, sedation, coma, or death. Meperidine can cross the placental barrier and has been found in breast milk, which can affect maternal and fetal well-being. The most common adverse effects of meperidine include respiratory depression, light-headedness, vertigo, sedation, nausea, vomiting, euphoria, biliary tract spasm, and urinary retention.4,6 PATIENT SAFETY ASPECTS OF PCA Although numerous benets of PCA have been chronicled during the past three decades, the processes surrounding PCA use can threaten patient safety. Numerous facilities that voluntarily share data have documented PCA errors,2,3 which may mean that PCA errors are more common than previously believed. In a comprehensive review of PCA medication errors, the reported incidence of harm was 6.5%, an unfavorable comparison to the 1.5% incidence of all other medication errors reviewed in the study.2 Errors associated with the PCA process were documented in each phase of the medication-use process, from prescribing, through transcribing, dispensing, administering, and monitoring.2 The medication-use process, therefore, may be the best place to make practice improvements to reduce the likelihood of errors while improving patient care. Prescribing The health care professional who initiates the decision for PCA use is the prescriber. Prescribers, many of whom are surgeons or anesthesia professionals, determine whether the patient is likely to need more than 24 hours of analgesic control after a surgical procedure. The prescriber is charged with appropriate patient selection8 and should plan to address any concerns (eg, abuse, addiction) that may affect the use of PCA but should not allow these concerns to prevent

Fentanyl Fentanyl, a pregnancy category C medication, is one of the more potent opioid analgesics. It is approximately 75 to 100 times more potent than morphine3; 100 mcg of fentanyl is approximately equivalent to 10 mg morphine or 75 mg meperidine. Fentanyl tends to bind with mu receptors and has a rapid onset of action because of its ability to rapidly cross the blood-brain barrier, but it has a short duration when administered parenterally. Larger doses of fentanyl can produce apnea. Known adverse effects of PCA fentanyl include hypoventilation, bradycardia, and sedation. Fentanyl interacts with other CNS depressants, which may preclude the products use.3 Meperidine Meperidine is a synthetic narcotic analgesic and is another product suitable for PCA use. Like other opioids, meperidine is classied as pregnancy category C. It is indicated for relief of moderate to severe pain. Compared with morphine, this agent has more kappa afnity and peaks faster but also dissipates faster, resulting in a shorter duration. Parenteral doses between 60 mg and 80 mg meperidine are equivalent to 10 mg morphine. The half-life ranges from three to eight hours in healthy individuals but increases as much as twofold in patients with hepatic impairment. A typical meperidine order may include an initial infusion of 10 mg, with a range of 1 mg to 5 mg per incremental dose. The lock-out interval can range from six to 10 minutes.4,6 Metabolism of meperidine results in a bioactive metabolite known as normeperidine, which has an extended half-life elimination period of up to 20 hours. Prolonged use of meperidine can result in accumulation of the metabolite and lead to serious CNS effects. For this reason, use of meperidine for PCA has decreased over time. A too-rapid administration of meperidine also can precipitate serious events. Another untoward effect associated with meperidine is aggravation of pre-existing convulsive disorders.4,6
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PATIENT-CONTROLLED ANALGESIA appropriate management of postoperative pain. Prescribers should be familiar with all modalities of pain management and should be comfortable progressing from one modality to another. A typical PCA order should identify the

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TABLE 3. Sound-Alike/Look-Alike Medication Errors1 Patientcontrolled analgesia agent

Morphine

patient, allergy information, analgesic product to be used, initial loading (ie, bolus) dose, basal rate, lock-out interval, and duration.

Sound-alike products
Hydromorphone Methadone Hydrocodone Morphine Bentyl Sufentanil Methadone Morphine

Look-alike products

Hydromorphone Fentanyl Meperidine

Magnesium sulfate Meperidine Haloperidol Bentyl Meprobamate

In patient-centered care, the prescriber (eg, surgeon, anesthesia professional, nurse practitioner) informs the patient and his or her designated support person(s) about the decision to use PCA. Errors that may occur during the prescribing phase involve incomplete orders, duplicate orders, improper dosage orders based on the patients laboratory results or other values, and 2 improper patient selection.

1. Hicks RW, Becker SC, Cousins DD. MEDMARX Data Report. A Report on the Relationship of Drug Names and Medication Errors in Response to the Institute of Medicines Call for Action. Rockville, MD: USP Center for the Advancement of Patient Safety; 2008:72, 84, 102, 109.

To thwart such errors, recommendations from the Institute for Safe Medication Practices (ISMP) include developing and deploying standard order sets.9 The use of preprinted order forms also can aid in ordering PCA therapies and is recognized as a best practice.10 Dispensing Pharmacists, by the nature of their training, are recognized as the experts in safe medication use and can facilitate the safe use of PCA. Part of their role in the PCA use process includes validating the original order, conrming allergy information, and serving as a general resource to other members of the health care team. Other important components of the pharmacists role are to ensure that product concentration is clearly displayed on the cassette or infusion

reservoir8 and to minimize the number of available concentrations. Pharmacists can assist in ensuring that products that have similar names are adequately separated and easily identiable, such as through use of tall man lettering (eg, DOPAmine, DOBUTamine).11 Several PCA products share names that either sound like or look like other products (Table 3).12 Errors that commonly occur during the dispensing phase involve improper replenishment of automated dispensing devices (ie, the devices contain the wrong product, either in terms of strength or medication). Perioperative nurses must be aware that restocking of automated dispensing devices is itself an error-prone process. Errors with dispensing devices have ranged from 1% to 7%.12 The American Society of Health System Pharmacists and the ISMP have both published authoritative standards for the safe use of dispensing devices.13,14 Administering and Monitoring After reviewing the prescribers order, the nurse obtains the product, either from the pharmacy or a dispensing device. The nurse must
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In one study, the majority of errors (54%) occurred during the administration phase.4 The highly technical and complex aspect of the required equip loading dose (if any), ment and supplies explains why many errors occur lock-out interval, and during this phase of the medication-use process. basal rate. Given that the majority of errors occur in the adNurses should recognize that the PCA cassette ministration phase, organizations that update PCA is a single-patient device. In fact, PCA vials or equipment must be aware of the human factors containers do not contain bacteriostatic or antiresearch related to any new device. To help en15 microbial agents. Such devices should not be sure that the right products are used, organizasteam sterilized or reused. When the PCA has tions are encouraged to adopt bar code medication been discontinued, unused portions should be verication processes.8,11 The nurse must secure the programmable infusion device (ie, pump) and discarded in accordance with established policies specialized tubing. The ISMP recommends that and procedures involving controlled substances. the administering nurse perform a nal, indepenBefore surgery, the perioperative nurse is idedent double check of the order and pump setally suited to provide education to patients and tings.16 Staff development plans should include patients family members. Nurses must recognize annual reviews of competency, especially if the that PCA use requires that the patient be an active clinical area uses temporary or supplemental staff member of the health care team. As such, the members on a regular basis. The entire process nurse should assess the patients cognitive funcconcludes with patient assessment and appropriate tion. The nurse should perform a mental and dedocumentation. velopmental status examination and determine the The adverse effects prole of PCA products patients level of consciousness to ensure that the points to other areas where nurses have important patient is an appropriate candidate for PCA.8 A best practice includes giving patients both written roles and responsibilities. Facilities that use PCA 8 and verbal education. should have sufcient equipment and training protocols in place. A smart pump, a specialized type of AORN Resources infusion device with preprogrammed parameters, should Clinical Answers/Medication Administration. AORN, Inc. be used. Also, it is now http://www.aorn.org/Clinical_Practice/Clinical_Answers/ common to use respiratory Clinical_Answers.aspx. monitoring equipment, such Medication Calculations/Conversions Pocket Reference. Denas a pulse oximeter and an ver, CO: AORN, Inc; 2004. http://www.aornbookstore.org/ end-tidal carbon dioxide product/product.asp?id 941988800&uip 76.25.37.100&sku monitor, when PCA is in MTK003A&mscssid ESBJ25HE72X09MJ4TKH8UDUQ62521RE1. use.17 Collectively, these Periop 101 Modules: Medications & Solutions. AORN, Inc. devices increase the safety http://www.aorn.org/Education/ContinuingEducation/PeriopModules/. of PCA.8 Safe Medication Administration Tool Kit. AORN, Inc. In Given that all of the analpress. http://www.aorn.org/Clinical_Practice/ToolKits/Tool_ gesic products have the abilKits.aspx. ity to suppress the respiraWeb site access veried January 10, 2012. tory system, nurses should be well versed in assessing
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then implement the PCA order by setting the parameters for the

PATIENT-CONTROLLED ANALGESIA patients respiratory status. The most effective monitoring protocol includes a standardized process for conducting an ongoing assessment of the patients level of pain, sedation, and respiratory status.8 In assessing the patients pain, the nurse evaluates the efcacy of the treatment and elicits the patients response in terms of comfort or discomfort. Because sedation precedes respiratory depression, early monitoring and documentation of sedation effects can be the nurses rst line of defense against potential overdose events. To facilitate this process, nurses should adopt one assessment scale to be used across the organization as a means of standardizing the process and improving communication among the health care team members, another best practice.8 Treating an overdose of a PCA agent should be aimed at establishing a patent airway and, if necessary, might involve assisted or controlled ventilatory support. After an airway has been established, additional overdose treatment regimens may include administrating a narcotic antagonist (eg, naloxone), oxygen, and IV uids, and providing other supportive measures, depending on the clinical condition of the patient. Organizations must ensure that rescue equipment is readily available in areas where patients receive PCA and ensure that staff members have demonstrated appropriate competence with the resuscitative equipment and protocol.8 Another important aspect of PCA safety deals with what is commonly known as PCA by proxy (ie, an unauthorized person presses the delivery button to deliver analgesic medication to the patient). This action increases the risk for harm. Perioperative nurses must educate the patients designated support person, family members, and other visitors about the purpose of PCA and the dangers of PCA by proxy.18 In December 2004, The Joint Commission issued a national safety alert regarding PCA by proxy and recommended that patients and family members be educated about the dangers.19

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Documentation of the entire PCA process and the education provided to the patient and family members should be evident in the medical record. This documentation should reect input from all members of the health care team. Documents could include the original history and physical examination report and treatment plan, preoperative teaching performed, the order sets, nursing assessments, and the medication administration records. From a quality improvement perspective, the entire process should be reviewed on a regular basis. Ideally, if the facility is located within a region in which there are many health care facilities, then there should be standardization across the region and within the professional schools.

CONCLUSION Patient-controlled analgesia is an effective treatment option for reducing pain. Because of known risks associated with IV medications, opioids, and the use of PCA devices, best practices should be established and followed to reduce opportunities for adverse events. Although PCA therapy is complex, incorporating best practices and minimizing variability throughout the medication-use process help decrease the potential for adverse outcomes. Perioperative nurses make many important contributions to safe medication use, and establishing standardized processes across organizations is vital to ensuring positive patient outcomes in pain management, particularly in regard to PCA use. This is another example of the key role perioperative nurses play in inuencing patient outcomes at the sharp end of patient care where the medication and patient intersect, the nal safety net in the medicationuse process. Editors note: The views expressed are those of the authors and do not reect the ofcial policy or position of the Uniformed Services University of the Health Sciences, the Department of the Defense, or the US Government.
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16. Part II: How to prevent errorssafety issues with patient-controlled analgesia. Institute for Safe Medication Practices. http://www.ismp.org/newsletters/acutecare/ articles/20030724.asp. Accessed November 10, 2011. 17. Maddox RR, Williams CK, Oglesby H, Butler B, Colclasure B. Clinical experience with patient-controlled analgesia using continuous respiratory monitoring and a smart infusion system. Am J Health Syst Pharm. 2006; 63(2):157-164. 18. Wuhrman E, Cooney MF, Dunwoody CJ, Eksterowicz N, Merkel S, Oakes LL. Authorized and unauthorized (PCA by Proxy) dosing of analgesic infusion pumps: position statement with clinical practice recommendations. Pain Manage Nurs. 2007;8(1):4-11. http:// aspmn.org/Organization/documents/PCAbyProxynal-EW_004.pdf. Accessed September 23, 2011. 19. Joint Commission on Accreditation of Healthcare Organizations. Patient controlled analgesia by proxy. Sentinel Event Alert. December 20, 2004;33. http://www .jointcommission.org/sentinel_event_alert_issue_ 33_patient_controlled_analgesia_by_proxy. Accessed September 23, 2001.

References
1. Miaskowski C. Patient-controlled modalities for acute postoperative pain management. J Perianesth Nurs. 2005;20(4):255-267. Hicks RW, Sikirica V, Nelson W, Schein JR, Cousins DD. Medication errors involving patient-controlled analgesia. Am J Health Syst Pharm. 2008;65(5):429-440. Hicks RW, Heath WM, Sikirica V, Nelson W, Schein JR. Medication errors involving patient-controlled analgesia. Jt Comm J Qual Patient Saf. 2008;34(12):734-742. Lehne RA. Opioid (narcotic) analgesics, opioid antagonists, and nonopioid centrally acting analgesics. In: Study Guide for Pharmacology for Nursing Care. 7th ed. St Louis, MO: Saunders Elsevier; 2010:69-72. Fine PG, Portenoy RK. The endogenous opioid systems. In: A Clinical Guide to Opioid Analgesia. Minneapolis, MN: McGraw-Hill; 2004:9-15. Stoelting RK. Opioids. In: Stoelting RK, Miller RD, eds. Basics of Anesthesia. 5th ed. Philadelphia, PA: Elsevier; 2007:112-122. Title 21 United States Code (USC) Controlled Substances Act. Subchapter 1 control and enforcement. US Department of Justice Drug Enforcement Administration Ofce of Diversion Control. http://www .deadiversion.usdoj.gov/21cfr/21usc. Accessed September 23, 2011. San Diego Patient Safety Taskforce. Tool KitPatient Controlled Analgesia (PCA) Guidelines of Care for the Opioid Nave Patient. American Society of HealthSystem Pharmacists. http://www.ashp.org/DocLibrary/ Policy/PatientSafety/IVSafety/PCAToolKitSan DiegoProject.pdf. Accessed September 13, 2011. ISMP develops guidelines for standard order sets. Institute for Safe Medication Practices. http://www.ismp .org/newsletters/acutecare/articles/20100311.asp. Accessed November 10, 2011. Weber LM, Ghafoor VL, Phelps P. Implementation of standard order sets for patient-controlled analgesia. Am J Health Syst Pharm. 2008;65(12):1184-1191. Misprogramming PCA concentration leads to dosing errors. ISMP Medication Safety Alert. August 28, 2008. http://www.ismp.org/newsletters/acutecare/articles/ 20080828.asp. Accessed September 23, 2011. Hicks RW, Becker SC, Cousins DD. MEDMARX Data Report. A Report on the Relationship of Drug Names and Medication Errors in Response to the Institute of Medicines Call for Action. Rockville, MD: USP Center for the Advancement of Patient Safety; 2008. American Society of Health-System Pharmacists. ASHP guidelines on the safe use of automated dispensing devices. Am J Health-Syst Pharm. 2010;67(6):483-490. Guidance on the interdisciplinary safe use of automated dispensing cabinets. Institute for Safe Medication Practices. http://www.ismp.org/Tools/guidelines/ADC_ Guidelines_Final.pdf. Accessed September 23, 2011. Morphine sulfate (morphine sulfate) injection solution. Daily Med. http://dailymed.nlm.nih.gov/dailymed/ drugInfo.cfm?id 6068. Accessed November 10, 2011.

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Rodney W. Hicks, PhD, RN, FNP-BC, FAANP, FAAN, is a professor of nursing at Western University, Pomona, CA. Dr Hicks has no declared afliation that could be perceived as posing a potential conict of interest in the publication of this article. Johnanna Hernandez, PhD, RN, FNP-BC, is an assistant professor and program director at Texas Womens University, Dallas, TX. Dr Hernandez has no declared afliation that could be perceived as posing a potential conict of interest in the publication of this article. Linda J. Wanzer, MSN, RN, CNOR, COL(Ret), is the director of the Perioperative Clinical Nurse Specialist Program and an assistant professor of nursing at the Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, MD. COL Wanzer has no declared afliation that could be perceived as posing a potential conict of interest in the publication of this article.

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EXAMINATION
CONTINUING EDUCATION PROGRAM

1.8
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Perioperative Pharmacology: Patient-Controlled Analgesia

PURPOSE/GOAL
To educate perioperative nurses about how to maximize outcomes and minimize risk in the use of patient-controlled analgesia (PCA).

OBJECTIVES
1. 2. 3. 4. Describe the use of PCA. Discuss the pharmacologic effects of opioid medications. Differentiate between four common opioid medications. Explain the role of the nurse in the PCA-use process.

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS 1. Intravenous PCA involves 1. allowing the patient to self-administer IV analgesic medications by using a timing mechanism. 2. having the nurse titrate medication to achieve an acceptable level of analgesia for the patient. 3. having the nurse and patient set up a timetable or schedule for the administration of the analgesia. 4. using an electronic infusion device with volumetric regulating capabilities. a. 1 and 4 b. 2 and 3 c. 1, 3, and 4 d. 1, 2, 3, and 4 2. Opioids exert strong _________________ effects. a. anti-emetic b. anesthetic c. anti-inammatory d. analgesic
Published by Elsevier, Inc., on behalf of AORN, Inc

3. _______ receptors are located in the brain, spinal cord, and intestinal tract. a. Kappa b. Mu 4. The differences in onset, peak, and duration of common opioids is a result of each products 1. ability to cross the placental barrier. 2. lipid solubility. 3. ability to cross the blood-brain barrier. 4. sensitivity to gastrointestinal activity. a. 1 and 4 b. 2 and 3 c. 1, 2, and 4 d. 1, 2, 3, and 4 5. Inhibitors of the cytochrome P450 enzyme system, which controls opioid metabolism, include 1. antifungal agents. 2. antibacterial agents. 3. chemotherapeutic agents.
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CE EXAMINATION
equivalent in dose to morphine. a. true b. false b. 1, 4, and 5 d. 1, 2, 3, 4, and 5 9. Some of the most common adverse effects of meperidine include 1. biliary tract spasm and urinary retention. 2. bradycardia. 3. euphoria. 4. hyperventilation. 5. nausea and vomiting. 6. sedation. a. 1, 3, and 5 b. 2, 4, and 6 c. 1, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6 10. After reviewing the prescribers order and obtaining the product from the pharmacy or a dispensing device, the nurse must implement the PCA order by setting the parameters for the 1. basal rate. 2. loading dose, if any. 3. lock-out interval. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

4. macrolides. 5. protease inhibitors. a. 2 and 3 c. 2, 3, 4, and 5

6. Practitioners should use the following parameters to achieve optimal analgesia when using morphine PCA for an opioid-naive patient: 1. 1-mg to 2-mg bolus. 2. 1-mg to 3-mg bolus. 3. six-minute lock-out interval. 4. self-administration dose of 1.5 mg to 3 mg per hour. 5. self-administration dose of 3 mg to 10 mg per hour. a. 1 and 5 b. 2 and 4 c. 1, 3, and 4 d. 2, 3, and 5 7. Approximately 1 mg to 2 mg of hydromorphone is equivalent to ______ of morphine. a. 10 mg b. 12 mg c. 14 mg d. 16 mg 8. Fentanyl can be used in the PCA approach and is

The behavioral objectives and examination for this program were prepared by Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no declared afliations that could be perceived as posing potential conicts of interest in the publication of this article.

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LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM

1.8
www.aorn.org/CE 8A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: 8B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: 9. Our accrediting body requires that we verify the time you needed to complete the 1.8 continuing education contact hour (108-minute) program:

Perioperative Pharmacology: Patient-Controlled Analgesia

his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Describe the use of patient-controlled analgesia (PCA). Low 1. 2. 3. 4. 5. High 2. Discuss the pharmacologic effects of opioid medications. Low 1. 2. 3. 4. 5. High 3. Differentiate between four common opioid medications. Low 1. 2. 3. 4. 5. High 4. Explain the role of the nurse in the PCA-use process. Low 1. 2. 3. 4. 5. High CONTENT 5. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 6. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 7. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 8. Will you change your practice as a result of reading this article? (If yes, answer question #8A. If no, answer question #8B.)

This program meets criteria for CNOR and CRNFA recertication, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Event: #12505; Session: #0001; Fee: Members $9, Nonmembers $18 The deadline for this program is February 28, 2015. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certicate of completion.

Published by Elsevier, Inc., on behalf of AORN, Inc

February 2012

Vol 95

No 2

AORN Journal

265