Nursing protocol for use of patient controlled analgesia - the Royal ...

PAIN SERVICE - ADULTSNursing Protocol for use of Patient Controlled Analgesia (PCA):1. Explanation should be given to patients by anaesthetist and/or nursing staff. "PainAfter Surgery" (RCHT023) patient information sheet to be given to patients preoperatively.2. A PCA care plan must be implemented.3. PCA must be prescribed on the prescription chart with full instructions asnecessary, of lockout time and mg per bolus. Disposable PCA has a set lockout of6 minutes (see page 2).4. Check current pump protocol matches the patient prescription.5. Before setting up a PCA machine ensure service record up to date. If out of servicean alternative pump must be used.6. Patients should have a pain score of mild pain or less before leaving recovery.7. Prior to the patient leaving recovery the asset number of PCA should be recordedon the recovery sheet and pain service pink database form.8. Syringes may be changed by a registered nurse who is competent in theadministration of IV drugs and undergone suitable training in the management ofPCA. Attained written and practical competence. Maintaining competence byregular use of skill and attending 3 yearly medical device training and clinicalupdates. Another registered nurse/midwife/learner must act as checker. Pleaserefer to the Role of the Checker Policy.9. An aseptic non-touch technique must be used. Please refer to the Role of theChecker Policy.10. Ensure clamp on administration set is released prior to commencing the infusion, toprevent accidental bolus.11. Before attaching the designated administration set, the syringe must be purged /primed by the pump.12. Ensure only designated syringes are used ie BD Plastipak 50mL luerlock.13. PCA should be administered via a specifically designed PCA giving set or aseparate IV cannula - a Y connector should not be used. PCA can be run via acentral line (see page 2 for Disposable PCA).Document Author Page(s) Version Last Review Reviewed By Next Review DuePain Service Adults - Pain 1 of 4 06 July 2012 Pain July 2015PCAServicesServices

14. If additional fluids are to be infused, with the exception of clear IV fluids, they mustbe run via a separate giving set in addition to PCA, i.e., blood, blood products,insulin or heparin. If a disposable PCA is in use, always use additional cannula forall fluids.15. PCA infusion pumps should be positioned no higher than cannula site to preventsiphoning of contents due to the effect of gravity.16. Prescribed night sedation may be given to patients with PCA but no other narcoticor sedation should be given unless prescribed by the anaesthetist.17. No intramuscular opioids should be given for the duration of the PCA infusionsunless sanctioned/prescribed by the anaesthetist. A warning label should beattached to the prescription chart advising of this.18. Naloxone should be prescribed prior to patient leaving recovery or on setting upPCA. incase of respiratory depression.19. Delays in renewing syringes should be avoided to achieve continuous analgesia.20. PCA giving sets should be changed every 48-72 hours or according to hospitalpolicy.21. PCA should normally be continued until it is appropriate to start administering oralanalgesia.22. Please ensure alternative analgesia has been prescribed before discontinuingPCA.23. Any opiate left in the syringe must be discarded into a denaturing kit. This shouldbe witnessed by two nurses and documented in the ward's wastage book.24. Keys for PCA machines should be kept together with the controlled drug keys bythe nurse in charge.25. On discontinuation, the pump should be cleaned and labeled according to hospitalpolicy and returned to theatres or pump library for storage.26. If equipment is faulty it must be returned to Medical Physics after being cleanedand labeled according to hospital policy.Clinical Observations:Monitoring should be documented on the MEWS Chart and AnalgesicAssessment Chart.1. Postoperative observations should be recorded every 15 minutes for 1 hour andthen every 30 minutes for the next 2 hours.Document Author Page(s) Version Last Review Reviewed By Next Review DuePain Service Adults - Pain 2 of 4 06 July 2012 Pain July 2015PCAServicesServices

2. Respiratory rate, sedation and pain scores must be recorded hourly until 24 hourspostop and then every 2 hours until the PCA is ceased. The frequency of otherobservations may be reduced after 12 hours unless otherwise clinically indicated.3. If a further loading dose is administered by an anaesthetist or specialist pain nursethen observations should be recorded every 15 minutes for one hour to ensurepatient's condition is stable.4. IV cannula site should be observed frequently for signs of inflammation re cannulacare plan.5. Disposable PCAFor use in designated areas onlyClinical observations remain the sameDisposable PCA set up by the anesthetist or pain servicesAdditional cannula required for fluidsLock out time for disposable PCA is 6 minutesProblems:1. Respiratory DepressionMorphine can cause sedation and respiratory depression. This is usually gradualin onset and detectable as a slow respiratory rate in a very sedated patient. Thesedation score must be regularly measured on every patient with PCA. If therespiratory rate is less than 8 and/or sedation score 3, remove handset/stopinfusion. Give oxygen 4 litres and inform medical staff. Consider giving naloxone.If respiratory rate 8 and sedation score

Pruritis is occasionally a side effect of morphine and can be treated with either anantihistamine eg, Piriton or by a low dose of Naloxone. Please seek medical advicein this instance.5. Inadequate AnalgesiaFollow RCHT guidelines. Ensure the equipment is functioning correctly and thatthe line is not occluded. Check that the patient understands how to use the PCA.Call pain team or anaesthetist – an additional bolus dose may be required oranalgesics other than opioids.Any problems should be documented in the appropriate patient records.ReferencesArfean. Z. Owen. H. (1995) Current Anaesthesia and Critical Care, 6, pp 76-80.Gell Walker V, Tye T (2000) Patient Controlled Analgesia Nursing Times Vol 96 No 25 pp38-39MacIntyre. P. Ready. L. (1996) Acute Pain Management: A Practical Guide.MacIntyre P (2001) Safety and Efficacy of PCA British Journal of Anaesthesia 87(1) pp 36-46MacIntyre P, Ready L (2001) Acute Pain Management: A Practical Guide WB Saunders,LondonRoyal Marsden Manual of Clinical Nursing Procedures. 7th EditionIVAC.PCAM Syringe Pump (Cardinal Health) Directions for Use.Role of the Checker Policy RCHT Document LibraryAseptic Non Touch Technique Policy RCHT Document Library Aug 2010Document Author Page(s) Version Last Review Reviewed By Next Review DuePain Service Adults - Pain 4 of 4 06 July 2012 Pain July 2015PCAServicesServices

Appendix 1. Governance InformationDocument TitleNursing guideline for the use of PatientControlled Analgesia [PCA] Adult.Date Issued/Approved: 27 July 2012Date Valid From: 27 July 2012Date for Review: 1 st July 2015Directorate / Department responsible(author/owner):Pain ServicesContact details: 01872 252792/ 2839Brief summary of contentsPain Services.Nursing guideline for the use of PatientControlled Analgesia [PCA] Adult.Suggested Keywords:Target AudienceExecutive Director responsible forPolicy:RCHT PCT CFTMedical DirectorDate revised: 23/07/2012This document replaces (exact title ofprevious version):Approval route (names ofcommittees)/consultation:Divisional Manager confirmingapproval processesNursing Protocol for the use of PatientControlled Analgesia.Pain services RCHTLearning and Development RCHTDr Paul Upton Medical DirectorGovernance RCHTDuncan BlissName and Post Title of additionalsignatoriesSignature of Executive Director givingapprovalPublication Location (refer to Policyon Policies – Approvals andRatification):Document Library Folder/Sub FolderLinks to key external standardsRelated Documents:Not required.Internet & Intranet Intranet OnlyDocument library and Pain Sub FolderGovernance Team can adviseRole of the checkerIntravenous Drug Administering

Training Need Identified?Registered Nurse competent inadministering intravenous medication.PCA training pack completed.Practical assessment completed.Medical devices PCA pump trainingattended/completed.Regular or 3 yearly updates.Version Control TableDateVersion11/04/2012 0511/04/2012 0523/07/2012 06Summary of ChangesNow on current hospital template andheadings.Page 2. NO 17Naloxone to be prescribed prior to patientleaving recovery or on setting up PCA.Added page 1 No2 A PCA care plan must beimplemented.Amended Page 2 Clinical Observations:Monitoring should be documented on the MEWSChart and Analgesic Assessment Chart.Changes Made by(Name and Job Title)Sharon DunstanSenior Pain SpecialistNurse.Sharon DunstanSenior Pain SpecialistNurse.Sharon DunstanSenior Pain SpecialistNurse.All or part of this document can be released under the Freedom of InformationAct 2000This document is to be retained for 10 years from the date of expiry.This document is only valid on the day of printingControlled DocumentThis document has been created following the Royal Cornwall Hospitals NHS TrustPolicy on Document Production. It should not be altered in any way without theexpress permission of the author or their Line Manager.

Appendix 2.Initial Equality Impact Assessment Screening FormName of service, strategy, policy or project (hereafter referred to as policy) to beassessed: Nursing guideline for the use of Patient Controlled Analgesia [PCA]Adult.Directorate and service area:Is this a new or existing Procedure?Pain ServicesName of individual completingassessment: Sharon DunstanExistingTelephone:01872 2527921. Policy Aim* To provide a guide to appropriate and safe administration inthe use of PCA analgesia.2. Policy Objectives* Available to nursing staff and medical staff.3. Policy – intendedOutcomes*4. How will youmeasure the outcome?5. Who is intended tobenefit from the Policy?6a. Is consultationrequired with theworkforce, equalitygroups, local interestgroups etc. around thispolicy?b. If yes, have thesegroups been consulted?c. Please list any groupswho have been consultedabout this procedure.To standardise practice resulting in safe administration ofPCA analgesia and reduce errors.Regular visits to patients with PCA analgesia ensuringguidelines are followed. Regular audit.Reduced datix reports received.Patient satisfaction regards to pain control.Patients, medical and nursing staff.NoN/APreviously practice development and infection control.*Please see Glossary7. The ImpactPlease complete the following table using ticks. You should refer to the EA guidance notesfor areas of possible impact and also the Glossary if needed. Where you think that the policy could have a positive impact on any of the equalitygroup(s) like promoting equality and equal opportunities or improving relationswithin equality groups, tick the ‘Positive impact’ box. Where you think that the policy could have a negative impact on any of the equalitygroup(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.

Where you think that the policy has no impact on any of the equality group(s) listedbelow i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.Equality Positive Negative No Reasons for decisionGroup Impact Impact ImpactAge √ Child health has its own guidelinesrelating to care of PCA analgesia.Disability√Religion orbeliefGenderTransgenderPregnancy/MaternityRaceSexualOrientationMarriage / CivilPartnership√√√√√√√You will need to continue to a full Equality Impact Assessment if the following havebeen highlighted: A negative impact and No consultation (this excludes any policies which have been identified as notrequiring consultation).8. If there is no evidence that the policypromotes equality, equal opportunitiesor improved relations - could it beadapted so that it does? How?Full statement of commitment to policy ofequal opportunities is included in the policyPlease sign and date this form.Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, ChyveanHouse, Penventinnie Lane, Truro, Cornwall, TR1 3LJA summary of the results will be published on the Trust’s web site.Signed ______Sharon Dunstan__________________________________Date _____23/07/2012____________________________________