Staff Responsible Procedure Rationale/Reason

Transcription

1 Subject: Patient Controlled Analgesia Date: October 2011 UPMC St. Margaret UPMC St. Margaret Harmar Outpatient Center Clinical Practice Council Policy #2005 Overview: To promote appropriate PCA use and monitoring of patients during PCA therapy. Patient selection and order for an infusion of opioids will be done by the physician following a clinical assessment of the patient. Patients to receive PCA must be able to comprehend instructions and access the button on the patient pendant for dose delivery. Staff Responsible Procedure Rationale/Reason 1. Infusion of opioids may be administered via the subcutaneous or intravenous route utilizing a continuous mode, a patient controlled mode, or the combined modality. 2. Patient teaching regarding PCA therapy, medication, and equipment will be done collaboratively between the physician and the nurse. All teaching will be documented in the Electronic Health Record (EHR). MD,CP, PA 3. The physician, CP, or PA will order the dosage of opioids to be administered based on the needs of the patient using the PCA Order Set in the EHR. MD, CP, PA 4. The physician s order MUST include a compatible IV solution, the rate, a PCA mode (PCA only, PCA + continuous or continuous only), a medication dose in milligrams or mcg, a lockout interval, and a one-hour limit. The order must contain all elements or it will not be initiated. a) A primary infusion

2 is necessary. Fluids and additives must be compatible with the prescribed PCA medication. b) The physician must indicate the amount of controlled analgesia to be administered each time the patient activates the PCA infuser and should be ordered in milligrams or micrograms. c) The lock out interval, the period during which the PCA cannot be activated and no analgesic will be delivered, may range from 5-99 minutes. The suggested lockout is 6-15 minutes. d) A one-hour limit must be ordered by the physician. This is the maximum amount of medication that will be delivered by the PCA infuser in one-hour dependent upon the drug used and the concentration. e) Approved medications: Morphine 5mg:1ml concentration (150 mg.) premixed vial Dilaudid 1mg:1ml Policy #2005

3 MD, CP, PA Pharmacist concentration (30 mg.) premixed vial For PACU and ICU only Fentanyl 50mcg : 1ml (1500mcg.) \\smh-nts- 6\SMHInfoCTR_Files\ Pharmacy\IVG\IV GUIDELINES.htm Vials are stable for ninety-six (96) hours and need changed only when empty or every 96 hours. 5. Loading Doses a) Bolus/loading doses of opioid may be ordered at the initiation of the PCA therapy to gain rapid relief of pain using dose titration. Peak dose effect occurs within 30 minutes following subcutaneous administration and 20 minutes following intravenous injection. b) Bolus/loading doses may be prescribed during the course of PCA therapy. c) All bolus/loading doses must be administered via the PCA infusion pump. 6. The opioid will be prepared and distributed by a pharmacist and should not be used as the primary

4 source of fluid for the patient. 7. Narcan, a potent opioid antagonist, will be readily available. Refer to Policy #2214 Naloxone Administration. 8. PCA is for use by the patient only. A warning label is to be placed on all PCA devices denoting for Patient Use Only! 9. The is responsible for administering the infusion according to the physician order. Infusion settings are to be independently verified by two (2) s when PCA is initiated, when programming changes are made, and syringes replaced. 10. There will be a shift-to-shift report by the going off duty and the coming on duty regarding patients with PCA. This report will include: a) Review latest physician prescription for PCA. b) Milligrams/mcg. used on the present shift. c) Visual inspection of pump that all settings are correct. 11. When transferring patient with PCA, the transferring as well as the from the unit receiving the patient will: a) Review latest physician prescription for PCA. b) Review milligrams/mcg. Used on present shift prior to transfer. c) Visually inspect pump to verify all settings are correct. 12. The PCA is cleared and amount used will be recorded every eight hours (each shift) at 0600, 1400, and 2200 hours and transfer PCA infuser key(s) must be kept in the AccuDose medication dispensing system in the unit s medication room. Administration sets for PCA infusers with be changed every 96 hours or with

5 /LPN /LPN /LPN /LPN /LPN each peripheral IV site change. Compatible secondary medications may be piggybacked into the upper Y site of the primary administration set while the PCA infuser is in use. 14. Upon discontinuation of the PCA, the remaining portion of drug in the injection vial is to be discarded, witnessed by a second, and documented in the EHR and AccuDose. 15. The /LPN is responsible for assessing the patient response to therapy according to the PCA Order Set and Pain Reassessment guidelines. 16. When PCA is discontinued, assure that an order has been entered into the EHR for further analgesia, if needed. 17. Record pump history. Situations that would indicate the need to record pump history include but are not limited to respiratory or cardiac arrest, evidence of narcotization, need to confirm programming or if pump malfunction is suspected. Set Up: 1. Obtain the following equipment: a) PCA infuser from SPD. b) PCA administration kit from SPD or supply room. c) Prescribed medication vial from pharmacy or AccuDose system. d) PCA infuser key (from AccuDose system). e) IV infusion pump. 2. Complete patient identification using the Bar Code Scanning procedure, or two approved patient identifiers during downtime, prior to initiating therapy. 3. Assure patient is not allergic to analgesic medication ordered. 4. Assure patient has patent IV

6 /LPN access. 5. Unlock door of PCA infuser with key. 6. Attach plunger to medication vial. 7. Connect medication vial to PCA tubing and manually prime set to Y connection site by pushing slowly on the pre-filled medication vial or use the PURGE function of the PCA pump. With either method of priming the PCA tubing, it must be primed BEFORE connection to the patient. Apply date tag to tubing. 8. Remove cap from Y injecton site and attach primary IV infusion set. 9. Prime primary set and lower portion of the PCA set. 10. Load primary set into infusion pump and set infusion volume and rate. 11. Load medication cartridge into PCA infuser system by following the Operator s Manual for detailed instruction or instructions printed on the side of the infuser or card attached to the infuser pump. 12. To change the infuser settings, follow the screen prompts and instructions on the user guide attached to the infuser. 13. Provide patient teaching on use of PCA infuser including: a) Instructions on operation of infuser in patient control mode. Press and release patient control button to dispense medication. An audible signal will acknowledge a successful request. No audible sound will be hard with attempts during the lockout interval. b) Instruct patient on

7 potential reactions to the medication such as nausea or rash. c) Review pain/pain relief scale. d) Explain that only the patient should press the PCA button. e) Document all patient teaching in the EHR. 14. Upon completion the use of the PCA: a) Disconnect PCA from patient. b) Dispose of any residual medication, witnessing disposal by two (2) s and document in EHR and AccuDose. Documentation: Document pca medication administration in Emar and document loading dose in emar if one is ordered Document ad hoc form when intiating pca setting/change in settings, upon transfer, and discontinuation of PCA Document in the Emar shift totals and pump verification Document pca education in IVIEW pt and family education Document waste of medication in ad hoc and accudose per HS>PH2000-PRO.. ORIGINAL: October 2004 PRECEDES: October 2011 REVIEW: October SPONSOR: Clinical Practice Council Department of Anesthesia Nursing Education

8 REFERENCES: (2006). Infusing Nursing Standards of Practice. Journal of Infus Nurs, 29(Suppl. 1), American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Caner Pain. 5 th ed. Glenview, IL: American Pain Society ; UPMC St. Margaret Nursing (2010). Administration and Documentation of Medications by Registered Nurse and Licensed Practical Nurse: Nursing Policy Pittsburgh, PA: UPMC ST. Margaret UPMC St. Margaret (2009). Controlled Substances: Hs-ph2000 PRO Control Substance. Pittsburgh, PA: UPMC \\smh-nts-6\smhinfoctr_files\pharmacy\ivg\iv GUIDELINES.htm Mary Barkhymer, MSN,, CNOR Vice President, Patient Care Services CNO (Chief Nursing Officer) Date