PCA & Epidurals

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Name some nursing interventions to help ensure patient safety when receiving epidural analgesia.

"PCEA" -> Patient Controlled Epidural Analgesic

How do you make the tubing of an PCA epidural?

* patients who refuse
* patients with coagulation defects
* patients with hypovolemia
* patients with infection
* patients with allergy to meds
* fetal condition that demands birth sooner than epidural can become effective

For what patients is an epidural CONTRAINDICTED (Name 6 patient situations)

* STOP PCA
* contact MD/House Officer (Resident)
* stimulate patient (try to arouse saying "take a deep breath, take a deep breath")
* administer reversal for opiod, e.g. Narcan 0.1mg IVP
*Apply 100% oxygen

What should a nurse do if a patient goes into respiratory depression or is unresponsive whilst using PCA?

1) ↑ BP & ↑ HR (a stress response)
2) ↑Blood Glucose (a stress response)
3) ↑ respirations and sometimes shallow breathing (a stress response)
4) ↑ ability of blood to clot (a stress response)
5) ↓ disturbed/deprived SLEEP

What are the negative physiological consequences of Pain? (Name 5)

1) an EXTRA, dose administered through the PCA device on top of the basal or PCA dosing. This might be given just before a painful procedure for example or say one mg each hour.
2) with a code or key (depending on the PCA machine)

1) What is meant by a bolus dose?
2) How is this administered?

1) children UNDER 5 years of age
2) OLD, CONFUSED patients
3) OBESE patients
4) patients with SLEEP APNEA
5) patients with RESPIRATORY ISSUES
6) patients who are taking DRUGS such as muscle relaxants THAT CAN POTENTIATE the effect of their medication such as muscle relaxants, anti-emetics or sleep medication

Name types of patients who are NOT good candidates for PCA.

1) confusing mL with mg
2) confusing PCA BOLUS doses with BASAL doses
3) Loading PCA dose where BASAL rate SHOULD HVE BEEN entered
4) Wrong lock out setting
5) Wrong concentration selected

Name some SERIOUS human errors in programming a PCA that nurses should be cautious of (Name 5)!

1) CONTINUOUS (in addition to the extra doses the patient can also administer)
2) patients who are used to receiving opiods, such as oncology patients

1) What does it mean to say that a PCA can deliver a basal IV infusion?
2) What patients are likely to receive these?

1) daily

2) every 3 days

1) How often are the PCA orders are reviewed?

) How often are PCA orders renewed?

1) hypotension
2) bladder distention
3) prolonged 2nd stage of labor (pushing stage)
4) migration of catheter
5) fever (with an epidural this does NOT indicate infection)

Name 5 adverse physiological effects of epidurals

1) Medication name
2) dose
3) concentration
4) demand (bolus) dose interval: This is measured in the TIME between each doses. For example 1 dose per 8 minutes
5) LOCK OUT interval: the ordered time within which the PCA will NOT release any more than the prescribed dosage.
6) nursing interventions
7) treatment of side effects

What comprises a complete order for PCA, i.e. name everything the prescriber must include in the order.

1) More satisfactory pain relief for patient (relief before pain gets too bad)
2) shorten's hospital stay
3) better able to deep breath and ambulate which means less post-op complications
4) Patient maintains control over pain
5) patients use LESS pain medication on PCA
6)reduced Nurse time/intervention by reduces the number of IM/IV administrations required

What are the advantages of PCA and epidural analgesia? (Name 6)

1) process
2) patient, nurse, pharmacist, prescribing physician

1) PCA refers to a PROCESS?/ EQUIPMENT?
2) Describe the above

1) RR < 8 breaths / min
2) HR < 45 beats / min
3) systolic blood pressure < 90
4) Temperature > 101
5) change in mental status
6) significant otor weakness
7) inadequte pain relief
8) unrelieved nausea/vomiging or itching
9) pump malfuncton
10) leakage, bleeding or signs of infection at catheter site.

What signs would required a nurse to notify the anesthesiologist? (Name 10!!)

1) The nurse monitors how many times the patient pushes the PCA button. If the patient pushes the button more than twice the prescribed dose interval either the DOSE is increased if possible, OR the DOSE INTERVAL is shortened. The results of these assessments are reviewed daily.

Describe the nursing assessments that monitor client response to PCA/epidural analgesia.

1) Vital signs (VS)
2) pain rating
3) type of pain
4) oxygen saturation
5) mental status
6) level of sedation
7) adverse reactions such as itching or nausea

What are some nursing assessments to monitor a client receiving PCA/ epidural analgesia

1mg (the other one is a concentration)

Which is a dose of medication? 1mg/mL or 1mg?

6 hours AFTER the epidural has been discontinued (just in case it needs to be restarted)

How long is IV access kept in an epidural line?

8.

Describe safe and competent nursing care of the client receiving PCA/ epidural analgesia

A) 6-8 minutes
B) the maximum dosage in a specified timeframe:
i.e. 1 HOUR lockout at 10mg

A) What is the dose interval usually for post-op pain?
B) What is the usual lock out interval for post-op pain medication?

A) if pt receiving PCA:

* <2 hours --> RN monitor every 30 minutes

* between 2-6 hrs --> RN monitor every 2 hours

* > 6 hours --> RN monitor very 4 hours

B) start monitoring intervals all over again

A) How often should the nurse monitor a patient receiving PCA?

B) What happens to the monitoring frequency is something (interval, dose, etc) changes on the PCA?

all three, but we do not want too much motor or parasympathetic, mainly sensory

The epidural is a SENSORY?/ MOTOR?/ SYMPATHETIC block?

basal

PCA?/ BOLUS?/ BASAL doses are used mainly for patients in oncology who are used to receiving opiods.

be in the room so that they can reinforce teaching when the MD leaves. Remember, when patients are sick their cognition is not there.

When MDs are teaching patients about how to use the PCA it is a good idea for the nurse to do what _____.

because epidural blocks the sympathetic response, which blocks the body's ability to raise blood pressure. Low blood pressure in combination with low blood volume is dangerous

Why would you NOT give an epidural to a patient who is hypovolemic?

a bell or light that sounds when the button is pushed to reassure the patient that a dose is on its way.

Sometimes patients in pain hit the PCA button repeatedly without waiting for the dose to work. What design feature on some PCAs prevents this?

below the spinal cord

Where in relation to the spinal cord is the epidural needle inserted

call MD if:
1) RR (respirations) <10/min
2) somnolence (sleepy) or confusion
3) sudden hypotension (i.e. sudden drop in BP), lightheadedness, dizziness
4) over sedation
5) inadequate analgesia
6) persistent nausea/emesis (aka vomiting) or purities (rash) (sometimes these symptoms pass on their own, but may not, in which case you should contact the prescriber.

When should a nurse monitoring a patient receiving PCA call the doctor? Name 6 situations

can

Epidural can be can?/ cannot? be regulated with PCA

a catheter is left behind and the medication flows into this catheter

What happens after the epidural needle is inserted into the patient's back?

Dilaudid
Morphine

Name two drugs that a NON anesthesiologist can order for pain. Name them from weakest to strongest

Dilaudid
Morphine
FENTANYL (e.g. for cancer patients)

Name THREE drugs that an anesthesiologist can order for pain. Name them from weakest to strongest

If the patient pushes the button more than twice the prescribed dose interval the prescriber might either increase the DOSE OR shorten the DOSE INTERVAL

Explain what is the outcome of the nurse monitoring how many times the patient pushes the PCA button.

IMPORTANT SAFEGUARD

If someone activated the PCA by proxy, effectively they have overridden the ___? of the PCA. There may be exceptions for parents of children to operate the PCA pump...check hospital policy.

In the epidural space at L3
the duramater, subarachnoid space and spinal chord are all too DEEP.

What cavity should the epidural needle be in for correct placement in the back? Between what vertebra?
What space is too DEEP for epidural placement?

is not

a nerve block in a shoulder IS?/ IS NOT? a kind of epidural

it reduced the urge to urinate, so monitor urinary output/distention

How does an epidural effect urination?

L & D
used for surgical procedures

What patients receive Epidural block

Narcan 0.1mg by IV push

What is the drug, dosage and route for the reversal med of opiod?

NO! Only regional

Do we want an epidural effect to be systemic?

nurses should:
1) maintain be proficient using the PCA pumps in the facility
2) PCA orders should always be written on PREPRINTED order sets
3) develop a list of patients who are good candidates for PCA and those who are NOT
4) When initiating PCA, transferring a patient to a new unit, or restarting or changing the dosage the pump TWO nurses must INDEPENDENTLY verify the patient ID, drug and concentration, pump settings and the line and site where the PCA will be infused.

Name some nursing interventions to help ensure patient safety when receiving epidural analgesia.

ONLY the anethesiologist NOT AN RN!!!

What health care professional administers a systemic narcotic in an epidural?

the PCA button looks like a call light and the patient may be pushing the call light thinking that they are activating the PCA.

What is a common design flaw of some PCA devices.

post-op
Oncology

Name 3 places in a hospital where you might see PCA?

Potential overdosing caused by:
1) Not good/dangerous for some patients (i.e. children UNDER 5 years of age; OLD, CONFUSED patients; OBESE patients; patients with SLEEP APNEA; patients with RESPIRATORY ISSUES; patients who are taking DRUGS THAT CAN POTENTIATE the effect of their medication such as muscle relaxants, anti-emetics or sleep medication
2) PCA by proxy (i.e. perhaps when the patient is already sedated, someone other than the patient can push the button and deliver the medication, for example the over concerned partner or family member)
3) pump problems
4) human errors

Name 3 concerns / safety issues related to PCA / epidural use.

The prescribed and programmes LOCKOUT interval prevents overdosing as the PCA device prevents more than a specified dose being delivered within the LOCKOUT time interval.

Discuss principles and safety features of PCA / epidural pump operation.

same as for a PCA

What monitoring is done for an epidural?

a scope of the bladder

What is a cystoscopy

sitting up, bent forward.

What position should a patient be in to receive an epidural?

spinal fluid leaks out

how can you tell if the epidural needle has gone too deep?

straight cath PRN for urinar retention

What urinary intervention is done for a patient who has had an epidural?

tell the primary care nurse. (it may just indicate that a PRN med should be given)

If vital signs are RED on Simchart what should the student nurse do?

they have more motor and sympathetic block than desired.

What happens to the patient if the epidural needle is inserted too deep?

They would NEVER catch up wit pain relief. Check the order or contact the physician to see if a bolus dose could be administered to 'reset' the pain cycle.

If a patient's pain was not sufficiently reduced prior to being connected to PCA what would happen? What should the nurse do?

transparent dressing

What kind of dressing is used for an epidural?

What she is > 5cm dilated

When is it too late to give a laboring woman an epidural?

When the patient is NOT IN PAIN. This means that they may be given pain medication BEFORE the PCA is set up.

When does PCA work best?

with the HOB raised 30 degrees

How do you position a client who is receiving an epidural?

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