Monitoring & PCA Use

[AllieSparksRN]

The med/surg unit I work on, which receives a majority of neuro and ortho post-ops, recently transitioned into using [continuous] end-tidal CO2 monitoring & [continuous] pulse ox monitoring on patients who have a PCA (patient controlled analgesia) pump running.

Prior to this, we just did [continuous] pulse-ox monitoring. Both types of monitoring are only "in place" when the patient is in bed - i.e. we unhook them when they're in the bathroom, out with therapy, etc. (So, not 100% continuous, but they are monitored most all of the time.)

Both the pulse ox and the ETCO2 monitoring are hooked up/linked into the vitals monitoring (we have MindRay) and this system doesn't cross over to the actual IV/PCA pump - so if the Pt is a mouth breather, for example, and the monitor reads "zero" the PCA keeps running. I've learned from nurses at other local hospitals that their monitors are somehow tied into their IV pumps and the IV "brains" will pause or shut off if readings are outside of set parameters. Our system doesn't do this. We have a "duck bill" nasal cannula apparatus available that is supposed to catch CO2 from mouth breathers but I've had little success with it the times I've implemented it.

Anyways. I'm just curious. Is my hospital way behind the times in implementing this kind of monitoring? What is your experience? Is your monitoring 100% continuous? Just when the patient is in bed?

I'm mainly wondering about other med/surg units but would welcome a response from anyone with any experience here. Many of the patients become annoyed with the additional cords and the monitor beeping, etc, (which is life - it's a hospital, not a hotel) but it's a change from how we used to do things.

Thanks for feeding my curiosity!

[ArmaniX, MSN, APRN]

I would imagine if a patient is ambulatory to the bathroom we wouldn't be too concerned with their CO2 levels or oversedation.

Can you set alarm limits / parameters that will alert you at the nurses station if they decide to take one too few of breaths? It's a tool to help you with your assessment of sedation and shouldn't be controlling your PCA or IV pump in my opinion.

[AllieSparksRN]

I would imagine if a patient is ambulatory to the bathroom we wouldn't be too concerned with their CO2 levels or oversedation.

Can you set alarm limits / parameters that will alert you at the nurses station if they decide to take one too few of breaths? It's a tool to help you with your assessment of sedation and shouldn't be controlling your PCA or IV pump in my opinion.

I agree with you on the ambulatory being not as worried about status.

Yep, you can set limits/parameters. They are only effective to a point - a mouth breather will constantly alarm because the monitor doesn't think he/she is breathing but they are. An excellent example of "assess your patient not only the equipment." I agree with you that it's a tool.

Thanks for your input.

[PPAHS]

As one of the members of the National Coalition to Promote Continuous Monitoring of Patients on Opioids (National Coalition to Promote Continuous Monitoring of Patients on Opioids - The Foundation - Association for the Advancement of Medical Instrumentation), the use of continuous end tidal and oximetry monitoring is being used by a growing minority - so, I applaud your use.

[MunoRN, RN]

The evidence is pretty clear that end-tidal CO2 is by far the most effective way to catch early signs that a patient is being over-narced, continuous pulse ox is actually of surprisingly little use yet it's far cheaper so it's the most commonly used, so kudos to your facility for using what works and not just what's cheapest.

I don't use the "duckbill" ETCO2 monitors much but supposedly they will monitor for both nasal and oral exhaling patients, if it's not picking up at all it may need some readjusting.

There are PCA's that can evaluate ETCO2 levels and be programmed to adjust both dose and lockout time depending on what it's reading.

I get that from the patient's view it can be annoying, and they're free to refuse any pain meds if it bothers them that much.

[dream'n, BSN, RN]

We use PCAs rather infrequently on my unit. When we do use them, the patients are on a continuous pulse oximeter, but we don't monitor ETCO2 levels.