PAIN MANAGEMENT Module 1 Patient Controlled Analgesia

Transcription

1 Learning Module Clinical Education & Training - Nursing Learning Module PAIN MANAGEMENT Module 1 Patient Controlled Analgesia For Nurses Acute Health First Issued: 31/10/2012 Page 1 of 22 Last Reviewed: 07/03/2017

2 Acknowledgment This document has been compiled utilising the existing resources available from Barwon Health Clinical Education and Training and the Barwon Health Staff. Barwon Health Clinical Education and Training PO Box 281 Geelong 3220 Enquiries to: (03) Position Service/Program Lead Reviewer Clinical Support Nurse Clinical Education & Training Contributor(s) Committees Clinical Education & Training Safety & Quality March Barwon Health This work is copyright. Except as permitted under the Copyright Act 1968(Cth), no part of this document may be reproduced in any form by any means graphically, electronically, mechanically or otherwise, without the express written permission of Barwon Health. In addition, this document and the information herein may not be stored electronically in any form whatsoever without the express written permission of Barwon Health. For information write to the Manager, Clinical Education & Training - Nursing, Barwon Health, PO Box 281, Geelong First Issued: 31/10/2012 Page 2 of 22 Last Reviewed: 07/03/2017

3 TABLE OF CONTENTS 1. GENERAL INFORMATION Introduction Competency Policies Approved Assessors Aim Objectives of Resource Package Acute Pain Service OVERVIEW OF PCA SYSTEMS DRUGS USED INDICATIONS FOR USE NURSING RESPONSIBILITIES Patient Education Monitoring and Documentation Frequency of Observations MANAGEMENT OF COMPLICATIONS Inadequate Pain Relief Sedation and Respiratory Depression Naloxone Protocol Nausea and Vomiting MANAGEMENT OF THE PCA PUMP Loading the Syringe Programming the Pump Starting the Pump Loading Dose Continuous Display Changing the Syringe Changing the Program Alarms History Call Back Function CARE AND MAINTENANCE OF PCA PUMP PCA KNOWLEDGE ASSESSMENT REFERENCES CONTINUING PROFESSIONAL DEVELOPMENT REFLECTION First Issued: 31/10/2012 Page 3 of 22 Last Reviewed: 07/03/2017

4 1.1 Introduction 1. GENERAL INFORMATION Patient Controlled Analgesia (PCA) offers an effective and safe means of administering opioid analgesia to patients who are able to assess their own pain level. This system allows a patient to administer a predetermined dose of drug in response to pain. The patient is given a pendant and instructed to press the button whenever they feel uncomfortable or before any activity that will cause pain. Benefits Improved patient satisfaction as the patient is in control. This has the added benefit of reducing anxiety, which in turn reduces pain. Reduced side effects such as sedation and nausea and vomiting. The patient has the ability to titrate the number of demands to any side effects they are experiencing. This also provides increased safety when compared to continuous opioid infusions. The ability to treat painful events such as coughing, getting out of bed and ambulating. This is an important feature of PCA, as it will reduce the incidence of complications such as chest infections, DVT and generalised deconditioning. PCA can also assist in determining a suitable dose of long acting opioid, eg. MS Contin, in patients with a chronic illness e.g. Cancer. NB. THE PATIENT MUST RECEIVE ADEQUATE EDUCATION FOR THESE BENEFITS TO OCCUR. (See Page 6) Delivery The most common route of administration is intravenous. However PCA can be readily applied to the subcutaneous, epidural and intrathecal routes. For information on Epidural PCA (PCEA) refer to Epidural resource package. Intravenous PCA is delivered via the IVAC PCAM pump. 1.2 Competency Policies If appropriate to the ward/unit/site they are working on, all Nurses working in Barwon Health are expected to complete a PCA competency skills assessment. Before this assessment is undertaken, the Nurse must pass an online knowledge assessment on GROW. No Nurse may care for a patient with a PCA until competency has been achieved. First Issued: 31/10/2012 Page 4 of 22 Last Reviewed: 07/03/2017

5 Two (2) Registered Nurses must carry out the following procedures; one of whom must be approved for PCA competency: Connecting PCA Changing a syringe These changes need to be signed, dated on the PCA Prescription Form by two (2) Registered Nurses. Syringes must be prepared in accordance with drug administration protocols available on PROMPT Changing any of the PCA program settings: o Program settings are authorised by the Acute Pain Service, Anaesthetist or treating Doctor and ordered on the PCA Prescription Form. Program changes need to be signed and dated on the PCA Prescription Form by two (2) Registered Nurses. o Administration of Naloxone as per protocol in the event of opioid induced over sedation. Only Registered Nurses with at least 12 months experience are permitted to administer Naloxone. o Before administration of any medication, the patient must be correctly identified using the 3 core identifiers. See Patient Identification procedure on Prompt for more information 1.3 Approved Assessors Clinical Nurse Consultant Pain Unit / Clinical Nurse Educators will carry out the assessing, or will direct the enquiry to an approved assessor on the appropriate ward. 1.4 Aim This learning module is designed for nursing staff to assess their knowledge and understanding of caring for patients receiving patient controlled analgesia. 1.5 Objectives of Resource Package 1. To provide sufficient background information in order that readers might develop an understanding of patient controlled analgesia systems in general. 2. To provide comprehensive information in relation to specific Barwon Health systems of patient controlled analgesia such that the reader can go on to confidently answer all questions, and perform all operations, required as part of the competency test. 1.6 Acute Pain Service The Acute Pain team visits every patient with a PCA daily and will assist the treating unit with ensuring appropriate analgesia is ordered for the patient. They may be contacted on During Hours: Pain Registrar Contact Switch Pain Nurse Consultant / ext Out of Hours: Anaesthetic Registrar on Call ext (this is linked to a mobile phone) First Issued: 31/10/2012 Page 5 of 22 Last Reviewed: 07/03/2017

6 2. OVERVIEW OF PCA SYSTEMS When commencing PCA the following parameters are prescribed on the MR PCA DOSE (sometimes referred to as the bolus dose) This is the set dose the patient receives each time they push the button. The dose is predetermined by the prescribing Doctor and can be based on varying factors, such as age and weight. Most patients will have the same dose. This is because they are able to press as frequently as is needed which means the overall dose is individualised to each patient. 2. LOCKOUT INTERVAL This is the set interval during which another dose cannot be delivered. The patient can press the button as often as they like but will only get a dose after the lockout interval has expired. This is a safety feature to prevent overdose. The most appropriate interval is 5 mins. Longer intervals can be programmed but will cause frustration and poor pain control. 3. CONTINUOUS (BACKGROUND) INFUSION A continuous infusion is sometimes used to supplement the patient s own PCA demands. However, the addition of a background decreases the safety of the system and increases the incidence of side effects such as nausea, vomiting and over sedation. A background infusion may be indicated if: There is a history of regular opioid use. This can be for cancer or non-cancer pain and includes drugs such as Panadeine Forte. The patient reports poor sleep due to the need to frequently use the PCA. In this setting a low background (eg.0.5mg Morphine) from 9pm to 6am may be beneficial. This is arranged in consultation with the Acute Pain Service (APS) 4. LOADING DOSE When commencing PCA it is important to reach effective serum levels quickly. Failure to attend to this delays the onset of analgesia and reduces the patient s confidence in the system. In the postoperative setting this is achieved by: Using the recovery room protocol. Administering small incremental doses titrating to effect. Programming a loading dose on the PCA pump. First Issued: 31/10/2012 Page 6 of 22 Last Reviewed: 07/03/2017

7 3. DRUGS USED Although Morphine remains the drug of choice for use in PCA, many patients find the side effects intolerable eg. nausea and vomiting. In addition, patients with renal impairment may develop side effects due to the accumulation of the drug and its metabolites eg. increasing sedation. In these settings it may be more appropriate to use drugs such as fentanyl or oxycodone. To improve safety and prevent inappropriate prescribing, one of the features of the PCAM (PCA) pump is the ability to have standardised protocols programmed into the pump. The following protocols have been programmed into the PCAM and in most cases will not need to be altered. However, changes to the protocols can be made within set guidelines. Refer to management of the PCA pump. (Page 15) This pump is for PCA delivery of medication Protocols may only be added by the Pain Team. PREPROGRAMMED MEDICATION PROTOCOLS DRUG CONCENTRATION PCA DOSE LOCKOUT INTERVAL Morphine 1mg/ml 1mg 5 mins Fentanyl 10mcg/ml 20-30mcg 5 mins Ketamine 4mg/ml N/A N/A Lignocaine 95mg/ml N/A N/A Hydromorphone 0.2mg/ml 0.2mg 5 mins Oxycodone 1mg/ml 1mg 5 min If a PCA order is prescribed outside the pre-set parameters it will be necessary to contact a member of the Acute Pain Service to have it modified. PCA is prescribed on the MR28. All drugs are prescribed for 60ml syringes. First Issued: 31/10/2012 Page 7 of 22 Last Reviewed: 07/03/2017

8 4. INDICATIONS FOR USE All patients who require regular and ongoing opioid analgesia should be considered for PCA. This includes: Acute postoperative pain Pain as a result of trauma Acute non-surgical conditions eg. Pancreatitis Patients who are nil by mouth Patients who may have large/unpredictable opioid consumption Patients who have visceral pain It is important to assess patients carefully and where possible consider the use of long acting oral preparations such as Oxycontin. The use of PCA for non-surgical conditions must be referred to the Acute Pain Service or on call Anaesthetist, who will review the patient before authorising the use of PCA. In the Emergency Department (ED), the decision to commence PCA will be made by the ED Consultant. RELATIVE CONTRAINDICATIONS 1. If the patient is unable to understand the concept of PCA use e.g. Language barrier or confusion, nurse initiated PCA or Nurse controlled analgesia (NCA) may be appropriate. If necessary, use an interpreter to educate the patient. Some translations are available from Wavelength / Clinical Refs (on left hand side) / Health Translations / Categories / Medical Procedures. If NCA is being used the RN should press the button for the patient if they are able to state they are in pain, their sedation score is less than three and respiratory rate greater than eight. Refer MR If the patient is unable to activate the pump e.g. severe arthritis or physical trauma, again NCA may be appropriate. 3. If the patient refuses. It is important to respect the consumers values, preference and expressed needs. Comprehensive education is essential to ensure the patient is making an informed decision. 4. Lack of trained nursing staff. It is an organisational requirement that there is an accredited nurse on each shift. 5. Children under the age of 5. Although Nurse Controlled Analgesia (NCA) can be used on the Paediatric Unit, it is considered unsafe to use PCA on children under five years of age. First Issued: 31/10/2012 Page 8 of 22 Last Reviewed: 07/03/2017

9 5.1 Patient Education 5. NURSING RESPONSIBILITIES Although PCA is a relatively simple technique to use, patient education is important to ensure the patient understands how to use it and why it is important to treat pain. Education can provide emotional support and help alleviate fear and anxiety. Ideally, education should begin pre-operatively with the ward pre-op education session and will need to continue after the analgesia is commenced. Education will need to be reinforced on return to the ward. In the ED there may be little time to prepare the patient but an information sheet can be given to relatives who may be able to help guide the patient. Patient education can be achieved by a combination of the following techniques: Giving the patient the opportunity to read and discuss the printed Patient Information Sheets or the relevant sections in the specific operative education sheets. Reinforcing the basic ideas of the PCA pump and its use once the pump is connected up. Patient education should cover the following points: Why it is important to have good pain relief. Many patients will elect not to move or cough to limit their pain rather than press the button. They need to know that lack of movement and untreated pain can delay recovery and lead to complications such as chest infections. Preventing pain or treating pain early is easier and requires less drug than treating severe pain. Why it is better for them to treat their own pain. The patient is the only one that knows how severe the pain is. By allowing the patient to treat pain as soon as it occurs, it prevents delays waiting for staff to administer drugs. It also allows them to treat pain before it occurs e.g. getting out of bed, performing physiotherapy or during painful procedures. How to use the control pendant (the button) to administer analgesia. The button should be pressed and released. Many patients think they need to hold the button down for it to infuse. Reinforce the idea that PCA is to provide sufficient pain relief for them to cough effectively and ambulate with minimal discomfort. This means pressing the button in advance ie. anticipating pain. The inherent safety of PCA. Reassure the patient they cannot become addicted when using PCA. Patients need to be told that the pump has been programmed to withhold the dose (lockout interval) if they press too often. It isn t necessary to tell them of the 5 minutes as this is often misinterpreted that they must press every 5 minutes. Never tell a patient they are pressing too often; it doesn t matter and it has been shown pressing the button may have a placebo effect. Reassure the patient that the nursing staff will be assessing them at regular intervals and that the Acute Pain Service or Anaesthetist will review them each day. When educating children it is important to educate the parents. Parents may become anxious about the child pressing the PCA button. It is also important to stress that only the child or the nursing staff are permitted to press the button. First Issued: 31/10/2012 Page 9 of 22 Last Reviewed: 07/03/2017

10 5.2 Monitoring and Documentation All observations must be documented on the Observation and Response Chart Although it is well documented that PCA is a superior form of analgesia when compared to continuous intravenous or intramuscular administration, it remains important to assess the patient regularly to ensure they are comfortable and to monitor for side effects of the drug. The following observations must be routinely documented for patients receiving opioids via a PCA pump: Pain score using the Visual Analogue Scale (VAS) (0-10) - at rest (Refer Diagram 1.) VAS Pain score (0-10) - on movement (eg. deep breathing and coughing). The patient should be asked to demonstrate a cough before scoring. Functional Activity Score (FAS) As well as subjective scoring, the patient s functional ability must be considered. The patient is asked to (or attempt to) perform a task appropriate to their injury/surgery and then rated on how pain affects their ability to perform the task. For example get the patient to deep breathe and cough following thoracic injury. (refer Table 2) Sedation score (Refer Table 1) - the patient is rated 0-3 according to the level of sedation / alertness. The aim is to gauge the effect of the opioid on the patient s level of consciousness, NOT to assess their neurological state. Therefore if a patient has their eyes closed most of the time, they are not awake and alert, they are asleep or drowsy and either easy to rouse or difficult to rouse. Respiratory rate. Changes to respiratory rate are a late indication of narcosis. Changes to sedation are a more reliable indicator. NB: Many patients have a reduced respiratory rate when asleep. Refer Escalation of Care - Adult Patients - University Hospital on PROMPT Diagram 1: PAIN SCORE using the Pain Visual Analogue Scale (VAS) No pain 0 10 Worst pain Using the 0-10 score, the patient is asked to rate their pain where 0 = no pain and 10 = the worst pain imaginable. Remember this is the patient s subjective report of pain and will often not reflect your assessment based on their behaviours. Therefore it is important to document the patient s rating and look for a change over time indicating efficacy of the treatment. Table 1 SEDATION SCORE 0 = Awake and alert 1 = Mild sedation easy to rouse 1 = 1s Asleep easy to rouse 2 = Moderate sedation unable to remain awake 3 = Difficult to rouse A = B = C = Table 2 FUNCTIONAL ACTIVITY SCORE (cough, movement) No limitation Mild limitation Severe limitation * Relative to baseline First Issued: 31/10/2012 Page 10 of 22 Last Reviewed: 07/03/2017

11 5.3 Frequency of Observations On commencement of therapy The patient is assessed at 30 minute intervals until the patient states he/she is comfortable or has a pain score <3 at rest and is able to cough effectively. The same observations are then continued 2 hourly for the following twelve (12) hours After 12 hours if the patient s pain score is below three (3) at rest, (or if the patient states that they are comfortable) continue to record these observations at four (4) hourly intervals. NB. IF A BACKGROUND INFUSION IS IN PROGRESS, CONTINUE TO MONITOR SEDATION SCORE AND RESPIRATORY RATE TWO-HOURLY. The following are documented only if they occur Nausea and vomiting Pruritus Urinary retention First Issued: 31/10/2012 Page 11 of 22 Last Reviewed: 07/03/2017

12 6.1 Inadequate Pain Relief 6. MANAGEMENT OF COMPLICATIONS If a patient continues to report a pain score above 3 at rest, is reluctant (or unable) to cough or deep breathe or has a FAS of C, a more detailed assessment is required. Possible causes are: Mechanical problem e.g. leaking intravenous access, pump failure Inadequate understanding of how to use PCA Inappropriate prescription Development of a complication Management: Check for leaks, pump problems etc. Question the patient and re-educate if necessary Review the pump history. If patient is making frequent demands especially during the lockout period, the prescription may need review by the Acute Pain Service - do not just tell the patient they are pressing too often. Question the patient regarding history of analgesic use. If on a regular opioid (including Panadeine Forte) the PCA dose may need adjusting Check if the patient has been given adjuvant drugs such as paracetamol, NSAID Contact the home team if there is evidence of a complication or patient deterioration. Refer to 6.2 Sedation and Respiratory Depression These are common side effects of all opioids and tend to be dose dependent ie. They occur more frequently in higher doses. There is also an individual patient variation in the onset of symptoms with some patients being more sensitive than others. Finally, there is an increased risk in the elderly and the very young. The management is prevention, which requires regular assessment and early intervention. It is also important to restrict the use of any other opioid unless prescribed by the Acute Pain Service /anaesthetist. The following flowchart details the management of opioid related over-sedation in patients with opioid PCA and/or continuous infusion. This chart is also printed on the back of the Intravenous/ Subcutaneous/PCA order form (MR28) First Issued: 31/10/2012 Page 12 of 22 Last Reviewed: 07/03/2017

13 MANAGEMENT OF RESPIRATORY DEPRESSION AND EXCESSIVE SEDATION Sedation score 2 Resps >9 Cease background infusion (if running) Apply O2 6LPM via Hudson mask. Continue with PCA without a background infusion Document in history Sedation score =3 Resps 8 As above Position patient on side and check airway Stay with patient and encourage to breathe Second person prepare and administer Naloxone 0.1mg. (adults only) Call MET Contact APS 6.3 Naloxone Protocol Naloxone (Narcan) is an opioid antagonist that is available in one (1) ml ampoules containing 400mcgs. It is available in all ward drug cupboards and arrest trolleys. Refer Naloxone Administration on PROMPT Administration should be titrated to reverse respiratory depression and sedation associated with opioid over-sedation, without reversing the analgesic effects. The indication for nurse initiated Naloxone as per protocol is: Sedation Score=3 and Respiratory Rate 8. Patients requiring Naloxone must have a MET CALL initiated. The correct dose of Naloxone must be prescribed and signed by a Medical Officer on the MR19 or MR28. Naloxone may only be administered by a Medical Officer or a Registered Nurse with at least 12 months experience. Patients who weigh less than 50kgs must have a written order on the Drug Order form MR21. To administer Naloxone, dilute 400mcgs (1ml) in n/saline (7mls) to make up to 8mls, ie. a concentration of 100mcg/2mls. Administer 2mls every 2-3 minutes (or as ordered on the MR21 for patients under 50kgs) until adequate alertness and ventilation is achieved. Naloxone has a short half life (45-60 minutes) compared with most opioids (3-5 hours) therefore in some circumstances, to prevent recurrent respiratory depression, the Medical Officer may commence a continuous infusion of Naloxone; this may require ICU admission. Given rapidly, Naloxone has some serious cardiovascular side effects including: Acute hypertension Pulmonary oedema Seizures Sudden death It is important to remain with the patient at all times until review by the medical team has occurred. First Issued: 31/10/2012 Page 13 of 22 Last Reviewed: 07/03/2017

14 OBSERVATIONS FOR PATIENTS DURING AND AFTER THE ADMINISTRATION OF NALOXONE Monitor respiratory rate and sedation score 2-3 minutely until the patient is breathing spontaneously with a respiratory rate 8 and a sedation score 2. Monitor BP and pulse while administering Naloxone. Continue to monitor respiratory rate and sedation score 15 minutely for 4 hours after administration. 6.4 Nausea and Vomiting PCA is associated with a reduced incidence of opioid induced nausea and vomiting, compared to intramuscular and continuous intravenous administration. However, nausea and vomiting (N&V) remains a common post-operative complication. It is important to note that N&V is not always attributable to the opioid. Management: First, do not assume it is caused by the opioid. Nausea and vomiting can also be caused by: Pain Anxiety Anaesthesia Type of surgery Gastric stasis General Measures: Rehydration Reduce anxiety Regular anti-emetics Adjust opioid dose Change to another opioid Consider using other drugs e.g. regular paracetamol, NSAIDS or Tramadol, that work synergistically with opioids and may decrease overall requirements (opioid sparing drugs) Do not cease the PCA as the first option. Contact the APS as necessary. Commonly used anti-emetics include: Ondanestron Droperidol Promethazine Dexamethasome Note: Maxalon should not be used for postoperative nausea and vomiting Refer Ward Treatment of Adult Post Operative Nausea and Vomiting (PONV) on PROMPT First Issued: 31/10/2012 Page 14 of 22 Last Reviewed: 07/03/2017

15 7. MANAGEMENT OF THE PCA PUMP The IVAC PCAM is the only pump used for patient controlled analgesia in Barwon Health. It has been programmed to accept Terumo 50/60ml syringes. There are two locks on the pump: One to lock the syringe cover. Second to lock the programming switch. Both locks are operated with the same key that is kept with the DD keys. 7.1 Loading the Syringe Ensure the syringe is correctly labelled according to the Prompt guideline Labelling of injectable medicines, fluids and lines. Unlock and open the cover Elevate and rotate the syringe clamp Insert the syringe into the slots on the plunger holder. Squeeze the finger grips on the plunger hold and slide the mechanism to the right until the syringe finger flanges fit into the V slot. Return the syringe clamp to securely hold the syringe. If the syringe is not correctly placed, the pump will alarm when you try to start it. (refer to 7.3) Once syringe is loaded: Remove the key and replace it in the programming switch Leave the cover open. Turn the key to the program position. Figure 1 OFF PROGRAM ON First Issued: 31/10/2012 Page 15 of 22 Last Reviewed: 07/03/2017

16 7.2 Programming the Pump There are six pre-set protocols to select from (refer Page 4) Select the desired protocol from the available options. If the order on the MR28 does not correspond with the protocol, changes can be made within limits pre-set by the APS. Changes to Protocol Select the correct drug from the available protocols Select modify protocol button Using the up and down arrows, select the parameter to be modified eg. PCA dose. Press the alter button Change the value using the up and down arrows Select the confirm button Press OK Start the pump 7.3 Starting the Pump Turn the key to the on position Confirm the protocol using the OK button Confirm the syringe type Press the green on switch Close the cover (this can be done without using the key) NB: By leaving the cover open it is possible to adjust the syringe, if required, without needing the key again to open the cover. 7.4 Loading Dose This function is rarely used as PCA is generally started in theatre and patients are given bolus doses as per protocol. However in ED this may be a desired option. (Note loading dose can only be set once, at initial programming) Select modify protocol button Select loading dose. Enter value Select confirm Select OK 7.5 Continuous Display When the pump is in operation the following screen is displayed. PCA AVAILABLE DEMANDS TOTAL 3 GOOD 2 DRUG INFUSED 2.0 mg 2.0 ml RATE: NB: When a PCA dose is being infused, the rate will change. First Issued: 31/10/2012 Page 16 of 22 Last Reviewed: 07/03/2017

17 7.6 Changing the Syringe Suspend the program using the orange stop button Open the cover using the key Change the syringe Press the green start button Close the cover Remove the key (There is no need to access programming function for syringe change) 7.7 Changing the Program If a change is made to the order on MR28: Suspend the program using the orange stop button Using the key turn to the program position. Select the correct drug from the available protocols Select modify protocol button Using the up and down arrows, select the parameter to be modified e.g. PCA dose Press the alter button Change the value using the up and down arrows Select the confirm button Press OK Start the pump 7.8 Alarms Alarms are indicated by a combination of an audible alarm, flashing amber STOP light and a descriptive message in the display. To silence the alarm, press the orange stop button, refer to the display and correct the problem. The following alarms appear on the display as they occur. Cover open: check cover and lock Drive disengaged: check finger grips and the position of the syringe Line occlusion: unlock and open cover, release pressure in syringe, identify and correct the occlusion Syringe error: Incorrect syringe size or clamp not fitted correctly Check handset: patients handset faulty or disconnected Battery low: 30 minutes operation remaining, plug into mains Battery exhausted: turn machine off, connect to mains, turn back on Syringe near empty: 6% of volume remaining AC power fail: pump not connected, running on battery Malfunction: internal problem, return to biomedical engineering NB: A Nurse attention warning is activated if the pump is left switched on for more than 2 minutes without starting the infusion. This alarm is 3 beeps and does not have a screen prompt. First Issued: 31/10/2012 Page 17 of 22 Last Reviewed: 07/03/2017

18 7.9 History The PCAM will retain all events in a rolling memory. A history of events can be obtained at any time by pressing the history button. There are four history screens: PCA demands this provides hourly totals of the number of demands the patient has made and the number of doses that have been delivered. This is presented in a bar graph. Drug infused This provides a record of the total amount of drug administered to the patient over the past 24 hours. Again this is presented as a graph. 24 hour review This is an hour by hour record of the last 24 hours, of PCA demands and total dose delivered. Event log This records all events since the New Patient was selected. It is not necessary to record any of these events but the nurse may find these useful when assessing patients Call Back Function This function is used when first setting up the pump and applies mainly to recovery room. It enables a program to be set up ahead of time and left switched on without the alarm going off at the 2 minute interval if not started. Insert the syringe and program the pump in the usual way. Hold the orange stop button down for ten seconds and select the call back time interval (10 to 90 minutes). If the patient is still not ready to start after the selected time interval has expired, repeat the procedure and select a further time interval. First Issued: 31/10/2012 Page 18 of 22 Last Reviewed: 07/03/2017

19 8. CARE AND MAINTENANCE OF PCA PUMP PCA pumps should be operated from mains power as a general rule and battery use saved for transportation and patient ambulation. Before returning the pumps wipe them clean with a damp cloth and secure the perspex door in a closed position. Please note that the cover is subject to breakage if an attempt is made to close it without disengaging the lock. Return pumps to the Post Anaesthetic Recovery Room after use. The key for the pump is kept on the DD key ring in each unit. First Issued: 31/10/2012 Page 19 of 22 Last Reviewed: 07/03/2017

20 9. PCA KNOWLEDGE ASSESSMENT You have now completed the reading for this learning module. Please proceed to the PCA knowledge assessment on GROW as the online component of this competency. First Issued: 31/10/2012 Page 20 of 22 Last Reviewed: 07/03/2017

21 10. REFERENCES D. Gould et al. Visual Analogue Scale (VAS). Journal of Clinical Nursing 2001; 10: IVAC PCAM Manual, Alaris Medical Johnson, C (2006) Measuring Pain. Visual Analogue Scale Versus Numeric Pain Scale: What is The Difference? Journal of Chiropractic Medicine 4 (1): Reiff, P.A., Niziolek, M.M. (2001) Troubleshooting tips for PCA, RN 64(4): Woods, M. (2000) Advanced skills update: patient controlled analgesia, Professional Nurse 15(6): First Issued: 31/10/2012 Page 21 of 22 Last Reviewed: 07/03/2017

22 11. CONTINUING PROFESSIONAL DEVELOPMENT REFLECTION Name of learning module Date: Time taken to complete module: hours What did I want to learn? What did I learn? How will I use it in my clinical practice? Name: Remove page and add to your CPD portfolio First Issued: 31/10/2012 Page 22 of 22 Last Reviewed: 07/03/2017