When is it appropriate to push the button?

[Used Foley]

Hello!

I just started working for hospice and I am wondering about a few things. When is it appropriate for an LVN to push the PCA button for a pt? I say "NEVER!" but I have a few scenarios I have seen during some visits without LVN present but I'm sure they post one overnight in certain cases.

Can an LVN in California push the button in any of these situation? LVN in california cannot push meds through a syringe through a saline lock/iv/etc minus your typical common iv fluids etc.

1. Pt diagnosed with cancer and is very weak and has a PCA pump. pt asks you to push the button for pain relief.

2. Pt diagnosed with cancer but does not respond to verbal or tactile stimuli and has a PCA pump. pt is moaning and has facial grimacing.

3. There is an order for LVN to push the button on a PCA pump when they made a determination CA pt who does not respond to verbal or tactile stimuli has facial grimacing and also is moaning and is unable to push button by self. They would probably do this to adjust base dosage.

When is it appropriate? Or better yet, where can I find literature about this?

[Hospice Nurse LPN, BSN, RN]

Hi Used Foley! Whenever I have a question about something being in the scope of my practice, I call the BON. I always get the persons name and document everything they tell me. I then have our office manager place the documentation in my personal file. Hope this helps!

[Sue Damonas, BSN]

I hate to sound stupid but if the pt or family are allowed to push the button, why not the LVN?

[Cardiac-RN]

It is never appropriate to push the button unless you are the patient- not the family, not a nurse. That is why it is called 'patient controlled analgesia'.

Here are what I consider to be some appropriate responses for your scenarios:

1. If the patient asks the nurse to push the button, the RN should call and get an order for a bolus dose/ quick acting medicine to address the pain.

2. A non-responsive patient is not a good candidate for a PCA pump. The RN should call and get orders to discontinue the PCA pump and start another method of administration for pain medicine: IV/IM morphine, roxanol, duragesic, etc.

3. I have never seen an order for an LPN to 'push the button' on an unresponsive patient. Again, in an unresponsive patient who is exhibiting signs of pain via facial grimacing or moaning, the RN should contact the physician to obtain orders for pain medicine to be delivered by an appropriate route.

Cardiac-RN, now working for Hospice.

[tewdles, RN]

Cardiac RN, in my region we use PCA pumps even when the patient is no longer able to push the button. In the home setting, this allows the family the ability to use the PCA feature to safely and economically provide additional doses to their loved one...while we control the frequency and dose.

In my region, the LPNs can provide the vast majority of medications that the RN can provide. There would not be an order for the nurse to push the button, so to speak...but my hospice employer has a policy that if we encounter a patient with a PAINAD of >4/10 we must treat...delivery of the normal prn dose would be one of the options the nurse would have.

Any practice questions really are the domain of the state's BON.

[millhouse]

Dr. should be able to write order for clinician bolus but needs parameters. Can't just say Clinician Bolus PRN.

[tewdles, RN]

Dr. should be able to write order for clinician bolus but needs parameters. Can't just say Clinician Bolus PRN.

yes, we generally have orders for clinician bolus' which are often substantially larger doses than the PCA dose. We also have standing orders which allow us to calculate the dose which could be given.

Most of the time, when the patient has been using PCA and then becomes too weak or confused to push the button I adjust the basal rate to provide them with the daily dose they had historically been getting.