Patient not using PCA

Guest 360983 · Apr 8, 2011

I would assess the patient's use of the PCA pump. There's a way to see how often they're hitting it and how often they're hitting it inside of the lockout period.

That may be good with your professors or it may come off as a bit smart-ass.

What else makes you worried about her RR? If she's in serious pain and it's prescribed, I would give her some narcs. You do want to consider that it could affect her LOC, which is already off with the confusion, but you need to do something to help her pain and I'm not sure that Tylenol or NSAIDs would cut it.

~Mi Vida Loca~RN, ASN, RN · Apr 8, 2011

My hypothetical postop patient is experiencing severe pain and has demonstrated confusion and anxiety about PCA use. PCA is delivering background morphine at 0.5mg/hr. No info about whether she has pushed the PCA button at all, but her demand dose is 1mg with a 10min lockout. My two priorities are 1 dealing with immediate pain, and 2 assessment of effectiveness of PCA / patient education.
My question is: are separate opioids appropriate in conjuction with the PCA, not knowing if she has been receiving more than the background dose? It seems like the way to go considering the severity of her pain, but she is already experiencing PONV and would I be risking respiratory failure? Is it better to go with a paracetemol/NSAID combination at this point, or is that too slow acting? I can't adjust the rate of her PCA myself, or force her to use it, and I can't educate her until the immediate pain has subsided.

She needs like a bolus or something to get the initial pain under control. Are you saying the confusion is about the pump? not that the patient is confused in general? Anyway, once the initial pain is under control she should be in a better mindset to understand the education on the PCA. You obviously would need to call the doctor to get the initial bolus ordered. 0.5 mg/hr is not much at all (if she isn't pushing the button), especially for someone in severe pain, get the doc to order 3-4 mg initially and than control with the regular dose and see if it works better. Were you given these amounts? 1mg Q 10 mins seems like a lot if the button was pushed every 10 mins and you also have a background running as well.

Anyway, always better to stay on top of pain in a case like this than chase it. So best thing would be to get he severe down to a good level, than educate and let the PCA take over. That's how I have always seen it done.

But I have experienced severe pain before and you're not really going to absorb any education being given while in the state. I am really good at breathing through pain, and even than, I have to focus on my breathing and need everyone else to shut up around me while I focus or the pain takes back over.

dudette10, MSN, RN · Apr 9, 2011

My hypothetical postop patient is experiencing severe pain and has demonstrated confusion and anxiety about PCA use. PCA is delivering background morphine at 0.5mg/hr. No info about whether she has pushed the PCA button at all, but her demand dose is 1mg with a 10min lockout. My two priorities are 1 dealing with immediate pain, and 2 assessment of effectiveness of PCA / patient education.

I'm not sure if I'm right, but I'll give this one a go.

It's unfortunate that your hypothetical question doesn't give information on the amount delivered by the PCA on demand. In real life, that info is immediately available to you and is part of the assessment of PCA effectiveness. (Damn nursing school BS questions!)

I agree with the others that you need to get the pain down to a manageable level before you can continue patient education on the PCA. Your patient won't absorb the info at this time.

I would first check orders for an IV bolus of another opoid, then switch to a ketorolac IV bolus if ordered if you can get the pain down to moderate levels with the opoid bolus. Once the patient is responding appropriately to you (not just the pain rating questions), then begin your patient reeducation on the PCA. Be prepared to repeat yourself during the post-op stay.

With this scenario, we could play "what if" all day. Given only the information in the scenario, however, this would be the action I would take.

I wish an experienced PACU nurse would chime in.

dudette10, MSN, RN · Apr 9, 2011

I just googled something that said in big, tall letters: NO ADDITIONAL OPIOIDS SHOULD BE GIVEN ALONGSIDE A PCA.

Did I just send my patient into respiratory depression? Good god...

ETA: Just found something that provides for RN PRN bolus of the same PCA pain med with VS parameters, if ordered by the anesthesiologist. Whew.

~Mi Vida Loca~RN, ASN, RN · Apr 9, 2011

I just googled something that said in big, tall letters: NO ADDITIONAL OPIOIDS SHOULD BE GIVEN ALONGSIDE A PCA.
Did I just send my patient into respiratory depression? Good god...
ETA: Just found something that provides for RN PRN bolus of the same PCA pain med with VS parameters, if ordered by the anesthesiologist. Whew.

I was going to say, they use PCA's on the Ortho floor a lot and that is what they do, they do a bolus of whatever they are getting, once under control the patient uses the PCA on their own from there. I have also seen Toradol given in conjunction with he pain (again once under control) to help to since the 2 together usually can get good results for short term since Toradol can't be given more than 5 days.

I had a patient the other day on Morphine hourly on ortho, her family really tried to encourage pain meds on her when she was doing good. I mean she just had major surgery and with what we were giving her she rated her pain a 2. (very good for what she had done) but she would sill be "when can I have morphine again, when am I due for my Norco, when can I have this" in between times, her family kept encouraging her to ask for more. We were trying to get her off he Morphine and over to Norco only, but her family insisted she needed IV meds. So we got an order for Toradol and I went to give it to her, family asked what it was and I said it's another form of pain reliever and we see good results with it in conjunction with the Norco. (I left out that it's not an Opioid), it worked good with the woman and she than rated her pain at a 1 which I told her was good and what we would hope for because we can't make all of the pain go away with a major surgery like that. This satisfied the woman and the family. At least until discharge when they realized toradol was "just" super Motrin and not stronger. :rolleyes:

Aeterna, BSN, RN · Apr 10, 2011

I'm a rather inexperienced nurse (a little less than one year, woo!) but I do a lot of pain management with oncology patients, as well as having some school clinical experience in PACU (mostly orthopaedics).

I agree with the above that:

1) Patient education can't really be effective if the patient is in a lot of pain.

2) Other narcotics should NOT be given in addition to the PCA.

First, get the pain under control. I don't know why the question has it that you can't check how many times the patient has pressed her button for a bolus because every PCA pump I've seen allows you to browse through the history. Quick tip, however: check the pupils - if they are tiny, the patient has been getting quite a bit of narcotics

I wouldn't say post-op nausea/vomiting is a good indicator of too much narcotics, though. I've seen patients in PACU throwing up plenty but nowhere near respiratory depression. Compare with another patient I saw sitting up and chatting in PACU with no issues, then closed her eyes for a few minutes, and stopped breathing long enough for her O2 sats to go down to 75%. Bottom line is that everyone responds to meds differently, so this is why you are always assessing, assessing, assessing!

You may have to assess her confusion. Is she experiencing some sort of post-op delirium? Is she elderly and have dementia? Or was prior patient education regarding PCA not thorough or effective?

Second, you may have to call the doctor if pain control is suboptimal. The MD may even get you to administer a bolus (the PCA pumps I've worked with allows you to do this) or may increase the continuous rate. The MD may even add a non-opioid analgesic, like ketorolac or acetaminophen. Ketorolac seems to work quite well. However, I highly doubt acetaminophen or ibuprofen alone will work on pain that severe.

And again, once you have the pain under control, stay on top of it. It's much easier to keep low pain low than lower severe pain. Once you have that under control, re-enforce teaching of the PCA...and, as said earlier, it may take several explanations throughout the day.