Is this ever an ok thing to do? When I received report this am the nurse told me that he and all the nurses have been pushing the pca pump whenever the patient seemed like he was in pain. We don't usually get post surgical patients and this was my first patient with a PCA pump but I definitely remember from school that not all patients are appropriate for a PCA pump. Luckily the doc rounded early this am and he d/c'd the pca pump because he agreed with me. Now I think it was laziness on the nurses part so they wouldn't have to go to the med room and draw up morphine. I did let my manager know. I also disconnected the pca pump and removed it from the patients room cause I just didn't feel comfortable with the situation.
On the one hand I could see the convenience of it cause the nurse is already in there while the patient seems uncomfortably but really anyone could press that pump while they're in there and I know there's a lockout on the pump.
I spoke with some surgical nurses about this and they didn't seem to think it was that much of a problem. In my mind I know I did the right thing but having the doc d/c the pump and getting an order for morphine IVP. What does everyone else do?
Once I had a pt who had some deficits from an old CVA that had a post-op PCA (surgery unrelated to CVA) and found her family pushing the button, to the point that her RR was 8. I grabbed it & told them in no uncertain terms that they weren't the ones allowed to do the pushing, even if they didn't think she could because of her stroke.
We got that PCA d/ced.
RNs never ever touch PCA buttons where I am. And, like suzanne said, our PCA buttons are labeled with bright orange stickers that they are to be touched by patients only.
Specializes in SICU, EMS, Home Health, School Nursing.
We are not allowed to push the button for the patient. We can encourage the patient to use it, but we are not allowed to do it for them. Sometimes we use our PCAs for just a basal rate that the patient has no control over. If it is ordered, a RN can bolus the patient through the PCA if they have the correct code.
I'm surprised to hear of patients who've gone into resper arrest or distress because family was pressing the button. Whether it's a family member or the patient, there is still a lockout for that very reason and the lockout dose is set by the doctor who surely sets it within safe parameters. Just because the button gets pushed does not mean the patient receives a dose.
Is this ever an ok thing to do? When I received report this am the nurse told me that he and all the nurses have been pushing the pca pump whenever the patient seemed like he was in pain. We don't usually get post surgical patients and this was my first patient with a PCA pump but I definitely remember from school that not all patients are appropriate for a PCA pump. Luckily the doc rounded early this am and he d/c'd the pca pump because he agreed with me. Now I think it was laziness on the nurses part so they wouldn't have to go to the med room and draw up morphine. I did let my manager know. I also disconnected the pca pump and removed it from the patients room cause I just didn't feel comfortable with the situation.
On the one hand I could see the convenience of it cause the nurse is already in there while the patient seems uncomfortably but really anyone could press that pump while they're in there and I know there's a lockout on the pump.
I spoke with some surgical nurses about this and they didn't seem to think it was that much of a problem. In my mind I know I did the right thing but having the doc d/c the pump and getting an order for morphine IVP. What does everyone else do?
Let me first say, I don't condone the pushing of a PCA button by staff.
First of all, what was the rationale for pushing the buttone when pt. "seemed" like he was in pain? I would like to know some background on your patient. Was you patient able to verbalize pain and/or comprehend pushing the button? If not, then they used Dougherty (or whatver NV scale you use in your hospital and bolus'd pt). Not the way it should be, but perhaps they couldn't get anyone to change his order? Not saying this is the case, but I noticed this was o/n and it can be very difficult in some hospitals to get this type of thing changed overnight.
I know I've had many a postop pt. who didn't do well on PCA. Here's the cycle, sleeping soundly, (pain increasing with pt unaware while sleeping), wake up in a tizzy, with 10/10 pain. Hit button several times until relief (usually about 10-20 minutes - enough for 1-2 doses, fall back to deep sleep, (pain increasing with pt unaware while sleeping), etc.
When I worked trauma step down we got a lot of postops who had been up more than 24h prior to their sx. You add the shock of trauma, preop intractable pain, post surgical pain, and exhaustion and you get a tough customer for a PCA. These guys usually do better with IVP narcs then percs in the morning with IVP narcs for brkthrough. Or just do the IVP narcs o/n and start the PCA in the a.m.
HTH, you gotten great feedback so far from my fellow posters.
Specializes in private duty/home health, med/surg.
The nurses pushing the button for the patient are risking their job and license, not to mention endangering the patient. If a patient is unable to comprehend that he/she should push a button to control pain, then they are not a candidate for having a PCA. There are a few instances where a PCA by proxy is ordered, and if so it should be clearly indicated by the ordering physician and included in shift change report. The nurse who got the order to discontinue the PCA did the right thing.
I'm surprised to hear of patients who've gone into resper arrest or distress because family was pressing the button. Whether it's a family member or the patient, there is still a lockout for that very reason and the lockout dose is set by the doctor who surely sets it within safe parameters. Just because the button gets pushed does not mean the patient receives a dose.
It is very possible for a patient receiving an appropriate dose to go into distress due to inappropriate dosing by proxy. The settings normally allow for the patient to be able to hit the button, say, every 6 minutes (just an example).
If the pain is controlled, the patient usually doesn't need to hit the button every 6 minutes to maintain the pain control. However, after ambulating, coughing, or turning, the patient may need to dose themselves every 6 minutes to catch up. As their pain gets under control due to the more frequent doses, they usually get sleepy. A well-meaning but ignorant family member might think they are doing the patient a favor by hitting the button for them after they fall asleep. Meanwhile, the patient's respirations are getting slower, and slower...
Also, a prescribing physician has no way of knowing how each person will react to the narcotics. Some people are just very sensitive to meds and will need to be Narcan'd on a setting that would normally be considered appropriate for even the most narcotic-naive person.
Specializes in Telemetry, Oncology, Progressive Care.
What is the logic in this statement?
The nurses didn't order the PCA pump, obviously.
You're right the nurses didn't order the pump and just because the doctor ordered it doesn't mean it was the right thing to do. The laziness part I was referring to was the fact that they didn't call the doc to get the pca pump d/c'd and get another method of pain relief ordered. I forgot to mention in my original post that this patient has dementia and is really only oriented to himself and that was why I believe he wasn't an appropriate candidate for the pca pump. He wasn't even able to tell me if he was in pain or not and I had to assess that using the FLACC scale.
I fail to see how you don't get the logic in my question/statement. Nurses are to question a doctors order and by not doing that it is wrong. Otherwise you wouldn't need a nurse in order to pass meds, now would you?
Specializes in Telemetry, Oncology, Progressive Care.
I believe that is what the first nurse who realized the patient wasn't managing well should have done.
Now the only point I am unclear on is when you removed the pump from the room, was that pre order or post. I will save any further comment until clarified.
Taitter :)
Just to clear some things up. When I received this patient he was actually starting his 3rd day of being on the pca pump so he had how many nurses who were managing his pain for him via the pca pump. When I got out of report at 7:30 I went into the room and the button wasn't even in the patients reach. By the time I finished doing everything the doc had gotten their but I would have no trouble removing the pca pump without a doctors order and especially with this particular doc. I have a good relationship with him and he will basically order whatever I want (within reason).
I had this patient before he went to surgery. From there he went to the ICU for a couple days and then I had him again yesterday. I was well aware of this particular patient and knew how confused he was etc. and that he was unable to manage his own pain. It was well documented in the chart that this patient had dementia. The particular surgeon who did his surgery knew of his dementia and this is the surgeon who ordered the pca. I am pretty sure that most of his kids were there so if there was any doubt of his ability to use the pca they would have been able to let the nurses know of his abilities.
i'm an old hospice nurse, and hate to see pts in pain, but you are right. never, never, ever should anyone but the pt be pushing the button. it's potentially fatal, and doesn't let staff know what the pts real pain level is.:w00t: good work!
In almost all cases I'd agree that pushing the PCA for the patient is never a good idea.
I would like to bring up one situation that I was in though, where I feel it was appropiate for the nurse to push the PCA button.
In this case I was the patient and I argued successfully to keep my PCA. I was completely unable to use my hands because I had IV's infiltrate at the wrist on both arms. My wrists and fingers were so swollen I was unable to bend them at all. I asked my nurse to push the PCA button for me and she refused on the grounds that it was only allowed to be pushed by the patient. After a bit of complaining, I spoke with my MD who agreed that if I ask for the button to be pushed that I am still the one in control. He specifically wrote the order for the nurses to push my PCA button at my request until the swelling had gone down and I was able to push the button myself.
In this case, my condition was temporary, and the CONTROL was still mine.
It was well documented in the chart that this patient had dementia.
I was thinking something along these lines. If the pt's cognition is not enough to use a PCA, then that would be documented in your assessment. It would just take 'putting 2 and 2 together' to figure out that the pt wasnt hitting the button.
The only time I hit the button for the pt is if it is totally out of the pts reach, ie. he's getting his bed changed, in transport/transfer in CT, that sort of thing. And in any instance like that I would ask the pt, 'do you want me to hit your button for you?'
....and of course, I try to premed before procedures, dsg changes, ect and have them hit the button before I move it away from them, i like to clip it to their id bracelet so it doesn't get away, always educate the family on proper use of the pca; and for my #1 pet peeve.... get them on PO meds asap!
I've seen nurses use the PCA to give the button an extra push before a dressing change or transfer/change of position. The only real problem I have with that is I doubt it is as effective as a bolus would be. Usually the scheduled PCA dose is pretty small. But the med is being administered by a licensed professional, who should be able to assess the need and the effect. In any case, if this is happening on an ongoing basis, the patient is either being overmedicated or is not PCA appropriate.
I guess I do have one other problem--it sets a bad example for the patient's family. More than one family has told me that another nurse told them it was okay to hit the button for the patient, usually while the patient is sleeping. I always explain that the patient will lose consciousness before he kills himself, but that they could kill him by doing it for him. If that doesn't persuade them, I get it d/c'd.
Specializes in CVICU, PICU, ER,TRAUMA ICU, HEMODIALYSIS.
When is it OK for the nurse to push the PCA button??
When you just got the patient up in the chair and he number and positioning of the infusion pumps, pleurevacs, O2 tubing etc. and the arterial line and CVP poles are separating the patient from being able to reach the PCA cord button. My husband was just such a patient in the hospital after surgery for bladder cancer and when he asked for his "pain button" we all looked at each other then searched until we finally found it. My husband asked if someone would push it for him; a very understanding and empathic nurse said, "Normally, this is a big, NO NO, but in this instance, its a YES, DEFINITELY. I am sure that that nurse will try to keep a closer eye on how she arranged the various apparatus from now on, so it was a good learning experience and I would have done thing. Critical thinking is separating following the book to the letter no matter what,from analyzing each situation, analyzing the "rules" and what situations led them to be written, drawing on previous evidenced based knowledge and using all of the above to make the best possible decision for the patient at that moment in time. There are no "all the time" or "never, never, evers" in nursing.
Elvish, BSN, DNP, RN, NP
4 Articles; 5,259 Posts
Once I had a pt who had some deficits from an old CVA that had a post-op PCA (surgery unrelated to CVA) and found her family pushing the button, to the point that her RR was 8. I grabbed it & told them in no uncertain terms that they weren't the ones allowed to do the pushing, even if they didn't think she could because of her stroke.
We got that PCA d/ced.
RNs never ever touch PCA buttons where I am. And, like suzanne said, our PCA buttons are labeled with bright orange stickers that they are to be touched by patients only.