PCA Problems!

[Virgo_RN, BSN, RN]

I just had a night from he##. I was handed a mess by the offgoing nurse. Patient had just returned from orthopedic surgery (we are a cardiac floor) on a PCA with MS, pain 10/10. Previous nurse changed to Dilaudid at shift change. We went in and verified settings. Patient not responding to the Dilaudid, come to find out the syringe had been broken and the med was going on the floor. Put in a new syringe, gave a bolus. Still not responding. Upped the dose. Still not responding. Upped the dose to the maximum allowable under protocol. This entire process took all night, and by the end of the shift, the patient was still in pain. I had to leave the next shift (noc) to call the doc.

I felt terrible A) That I could not get this patient's pain under control and B) That I had to leave the task of calling the doc to the noc shift.

I hardly ever see PCAs, as we are a cardiac floor and our patients either get PO or IV push meds (even post OHS). The only reason this patient was on our floor was that she had been hyperkalemic, so she needed to be on tele. However, her hyperkalemia had resolved and she no longer needed to be there! She should have been sent to ortho after her surgery. Their pain protocols there are different, and her pain would have been managed much better from the start.

I know that I did the best I could and followed all the protocols, but I still feel like the worst nurse in the world and a horrible human being.

I probably should have called the doc earlier in the shift, but I felt that I needed to at least get her up to the maximum hourly dose and see if that would be effective before calling the doc.

[leslymill]

Your vent is understandable.

You did what was reasonable and appropriate with unfortunately a poor unreasonable outcome.

Hindsightedness always comes too late though.

Live

Learn.

[OC_An Khe]

The hard lessons I learned about this profession is that even when we do things perfectly, you can end up with a bad outcome. And looking at experiences in hindsight is also one of the ways we learn.

[Tweety, BSN, RN]

You did the right thing by using all the orders at your disposal and upping the dose to the max first. I feel you did the wrong thing by leaving your patient in uncontrolled pain without calling the doc again.

I presume you also checked for compartment syndrome or other complications, as uncontrolled pain could be a sign of trouble.

Not all patients do well with PCAs, some need a continuous drip, some need breakthrough p.o. meds, some just would rather the nurse do the work and give the meds as needed.

I work trauma, so trust me I know that working with patients with uncontrolled pain can be a challenge, I've woken up many a doc in the middle of the night for pain medication. I also know the terrible feeling you're experiencing when at the end of the day you're patient's pain is uncontrollable. Unfortunately sometimes it take a good while before a medication regime is found that works for the patient, and it does spill over into the next shift for them to continue to try new things.

As someone said, chalk it up as a learning experience.

[Virgo_RN, BSN, RN]

Yes, I did think of compartment syndrome. I was really glad for my clinical rotation on ortho! There were no s/s, and this pain issue had been an issue since prior to her surgery. She had been verbally abusive prior to her surgery as well, so her comments that she was "homicidal" and that the charge nurse had almost gotten "kicked in the head" were not a new behavior.

I forgot to document a couple of findings in my nursing notes, and I was thinking of going in and doing a late entry today. I'm not sure how appropriate that is, but I really want to CMA here. This lady had been complaining that we weren't doing enough for her for days, and had even alleged discrimination and demanded to talk to the charge nurse.

One of the findings was that even after I explained how the PCA works for the third or fourth time, the history showed that in the nine to ten o clock hour, she had only pressed the button four times and received three injections. She could have had six. It is my understanding that most of the time, people in a lot of pain will press the button quite frequently, and in doing so, will get their max hourly dose. She was not getting all the med she could, and in fact, was only getting half, because she was not pressing the button enough. I did explain this to her. She kept saying she didn't want the PCA because she didn't believe it would work, and she wanted us to do all her pain meds IV push. At one point she tossed her PCA button aside and refused to use it. I told her that she is not getting all the med she can from the PCA because she is not pushing the button enough, and I implored her to spend the next hour pushing the button as many times as she wanted, and that when she was getting the maximum dose, if her pain was not relieved, we would go on to the next step.

When I tiptoed in to check on her (didn't want her to know she had an audience in case that changed her behavior), she was lying quietly with a washcloth on her forehead. It wasn't until change of shift that she started stirring and fussing again.

Now I'm not saying she wasn't in pain. I do believe she was. But I also believe there were other factors involved including noncompliance with the PCA. She was cognitively and physically able to use the PCA, but psychologically, something was preventing her from accepting it.

You know, it's funny, because it was explained to her twice, once by another nurse, and once by me, that the PCA gives her control over her pain medication. Both times, she would start arguing about how if she had control, she wouldn't be there in the first place, or she would tearfully change the subject completely. I don't think she wanted control over the PCA; I think she wanted control over the nurses. I think she really wanted to be fussed over. I'm not denying that she was in pain; I really think she was. But I also think she was playing games that were interfering with effective pain control.

I'll be curious to find out what happened. Hopefully she got transferred to ortho today. They are far more equipped to handle post op pain, and their protocols give them far more flexibility in choosing an approach that works for the patient. Maybe they got a doctor's order for PRN ativan too.

Of course, it all becomes so clear at three am when I'm trying to sleep, not when I'm actually in the middle of this situation.

[CarVsTree]

One of the findings was that even after I explained how the PCA works for the third or fourth time, the history showed that in the nine to ten o clock hour, she had only pressed the button four times and received three injections. She could have had six. It is my understanding that most of the time, people in a lot of pain will press the button quite frequently, and in doing so, will get their max hourly dose. She was not getting all the med she could, and in fact, was only getting half, because she was not pressing the button enough.

This is where your misunderstanding of PCA's comes in.

If your patient is not pushing the button frequently, but is still in pain, she may be hitting the button (max dose) which knocks her out. Then wakes up in agonizing pain, hits button, knocks her out... etc. This is a case where your patient may do much better with percocets & ms/dilaudid/fentanyl IVP for breakthrough.

Also, a large component of pain is psychological... For instance, they recently did a study where they had recent AKA patients see a reflection of a leg that should be there which reduced their phantom leg pain....

So, if your patient thinks the PCA won't work, it won't work. I think you tried really hard to help your patient, but 8-12 hours is too long to go (just on your shift) without adequate pain control. The MD should have been called earlier rather than later in the shift. Also, didn't you say pt. was having unctrlled pain prior to your shift. That is a LONG time. Doc should have been called again and alternative to PCA should have been attempted. Esp. since pt. said PCA doesn't work for her.

Just want you to know, I think you did your best. Don't think I would fair much better with a true cardiac pt. being thrown in my lap. I'm surprised your ortho floor doesn't have tele. They should definitely get it!

[Virgo_RN, BSN, RN]

I see what you're saying. I was working within the protocols of our facility and my charge nurse was completely aware of the situation. I think I did my best, and unfortunately, it was not good enough.

At any rate, things never did get better. She was discharged home today since we weren't able to do anything for her.

[Tweety, BSN, RN]

It does sound like there were other psycho-social issues going on with this patient, and that no matter what you were in a lose-lose situation.

I hate it when a patient complains "this isn't working" and the history reveals an underuse. Often it is like the above poster says, it works for a few and they wake up in pain, this happens on noc shift often. These are the patients that eventually I give up on and d/c the pca and talk the doc into p.o. meds with IV for breakthrough.