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What are the reason for using a PCA or Epidural?
- Better pain control
- Patient will be able to ambulate earlier
- patient will be satisfied with a better pain relief
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What's the definition of Patient Controlled Analgesia?
Client can controls IV delivery of an analgesic by pressing the button on a delivery device
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When is a PCA used?
- post-op
- trauma pain
- labor/delivery
- sickle cell crisis
- chronic pain
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Which patients are better candidates for a PCA?
- be able to learn how to use, why use, and when to use
- physically able to use the pump
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What are the most common used medication in a PCA?
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What are 8 advantages of having a PCA?
- 1. Constant serum levels of opioid
- 2. reduce dose of opioids used
- 3. better pain relief
- 4. fewer side effects from opioids
- 5. decreases complication with patient
- 6. No need for any IM analegesics
- 7. allows client to sleep at night while minimizing daytime drowsiness
- 8. client becomes independent
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What are 5 disadvantages of having a PCA?
- 1. patient doesn't get pain relief because they mistake the button for another button
- 2. patients family comes in and uses it
- 3. pump fails from not giving the right amount of dose
- 4. nurse inaccurately set up the pump
- 5. nurse fails to continue monitoring the patient
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If a patient experiences and overdose from a disadvantage of the PCA pump what is the nurse going to administer?
NARCAN
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What is one condition that is contraindicated for using a PCA due to increasing the risk of respiratory depression?
Sleep Apnea
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What's the initial thing a nurse has to do with a PCA at the beginning of the shift?
check the HISTORY button and compare to MD order
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What is the loading dose?
- initial dose to get medication on board.
- 1 time dose only
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What is the basal infusion rate?
continuous infusion rate 0.5 ml/hr
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What is the PCA dose?
the demand dose- the dose the patient gets every time they push the button
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what is the bolus dose administered by RN?
A dose given for breakthrough pain
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what is the 1-4 hour dose limit?
the maximum dose amount the patient can receive including (basal rate, pca dose, loading dose, bolus)
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What is the lockout interval?
time patient has to wait between each dose they get 8-10 mins
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What are the things you need to educate the patient about when it comes to a PCA?
- 1. medication
- 2. purpose and benefits of pca
- 3. side effects & when to notify RN
- 4. Goal for pain control
- 5. How to use PCA
- 6. When to use PCA
- 7. Lockout interval/PCA dose
- 8. Inability to overdose
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What are the steps in setting up the pump?
- 1. attach the pump to a pole 10 inches above infusion site
- 2. attach med syringe and prime PCA tubing with medication
- 3. prime primary iv line with NS and insert to IV pump
- 4. Connect tubing from PCA pump to primary line at Y site closest to patient
- 5. set pump according to MD orders
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Is the usage of a PCA Pump have to be verified by one or two nurses?
2 rns independently verify medication, dose, rate
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What are the steps in changing the medication syringe?
- 1. 2 nurses needed to verify
- 2. check MD orders
- 3. obtain correct med
- 4. raise top bracket-remove old syringe
- 5. uncap new syringe-place in chamber & slide down bracket
- 6. change tubing if changing new med
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What are the essentials the nurse needs to monitor within 1 hour of giving loading dose and EVERY 2hr for the first 24hrs then Q 4HRS & PRN?
- respiratory rate
- sedation level
- 02 stat
- pain
- VS-BP, pulse
- iv access
- s/sx of overdose
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When should the amount of med delivered, # of attempts, delivery of PCA demand dose, and basal dose be evaluated?
every 4 hours
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When should the patients pain intensity, sedation level, respiratory rate and O2 stats be evaluated?
- within 15 minutes of first dose, if the concentration or rate change, any pump change, any supplemental narcotic or sedatives given
- then every 2 hours for the first 24 hours then every 4 hours until pca discontinued
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When should the nurse document and monitor the medication, dose, basal rate, #of injection, # of attempts, total narcotics given?
every 8 hours
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When a nurse is assessing a patient for a sedation level how is the sedation scale interpreted??
- 1=awake and alert
- 2=sleepy/drowsy
- 3=arouses to verbal stimuli only
- 4=arouse to physical stimuli only
- 5=somnolent/difficult to arouse
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What are two standard orders (things that are not to be done) when using a PCA?
- 1. Meperidine (Demerol) should NOT be used in a PCA
- 2. NO additional IV/IM/PO narcotics should be given unless ordered by MD
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What should the nurse do if the clients pain continues or gets worse?
- assess patients pain (PQRSTU)
- make sure the primary fluid is running
- look at the # of delivers vs. attempts
- assess for any other complications
- check iv site for kinked or infiltrated
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What should the nurse do when the MD has ordered for the PCA to be discontinued?
- 1. Give PO meds before PCA is discontinued
- 2. take away the button
- 3. give them the basal dose
- 4. give them PO
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If a patient becomes overmedicated how can you explain the reason for this to their family and what should the nurse do?
- happens from patient pressing the PCA button to many times
- nurse stops dosage
- sit patient up and ask them to take deep breaths
- give patient supplemental oxygen
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Is it safe to use a PCA on a pediatric patient?
- yes for the age of 8-9
- as long as they understand the concept
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What should a nurse know about a PCA given to an elder patient?
- sensitive to analgesic properties this is a side effect of opioid
- they have slow opioid metabolism and excretion
- should start low and go slow
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What is the definition of an epidural administration of analgesic?
catheter inserted into potential space
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when is a epidural used?
- post op
- abdominal surgery
- labor/delivery
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What are the most common used medications used in a epidural?
- opioid
- local anesthetics
- both
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how does an epidural work and deliver medication?
- medication is delivered through diffusion thru dura mater in CSF
- blood vessels in epidural space transport med systemically
- med is absorbed by fat in epidural space creating a depot for slow systemic release
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What are the 4 advantages of a epidural?
- 1. lower total dose of opioids required to control pain
- 2. fewer side effects to opioids
- 3. client can ambulate earlier
- 4. client is less drowsy
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What are the 5 disadvantages of having a epidural?
- 1. increase risk of respiratory distress
- 2. catheter may migrate into subarachnoid space causing dangerously high levels of med
- 3. urinary retention
- 4. motor or sensory changes
- 5. require frequent monitoring
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Beside a patient having a epidural what other patients are at increased risk of developing respiratory distress?
- age >70 yrs
- receiving concurrent CNS depressants
- renal, hepatic, cardiac impairment
- pulmonary impairment (sleep apnea, ICP, COPD, asthma)
- upper abdominal or thoracic surgery
- obesity
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what are contraindication for a patient to have a epidural?
- use of anticoagulants
- taking herbal meds
- has abnormal clotting studies
- history of multiple abscesses
- sepis
- skeletal or spinal abnormalities
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Which type of pump and tubing used for an epidural?
- EPIDURAL ONLY pump
- tube with no Y-ports
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How often should a patients SpO2 be monitored while with a epidural?
continuous monitoring until 12 hours after infusion discontinued
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How often should the nurse monitor a patients pain intensity, sedation level, respiratory rate with a epidural?
- within 15 minutes of first dose, if the concentration or rate change, any pump change
- then every 1 hour for the first 24 hours then every 2 hours until 12 hours post discontinued
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How often should the catheter insertion site, motor/sensory function/CMST of lower extremities, BP and Pulse, and temp?
Every 8 hours and PRN
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What are some common side effects the nurse should be aware that could happen from an epidural?
- 1. urinary retention/constipation
- 2. nausea/vomiting
- 3. pruritis
- 4. headache
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If a patient has a epidural what is important for a nurse to make sure is within reach?
- 1. oxygen equipment
- 2. bag/valve/mask
- 3. narcan
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Where is the best place for a patient to be with a epidural?
near the nurses station for frequent monioring
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What is the priority of the nurse to check before the patient is first going to ambulate?
orthostatic BP
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When it is important for a nurse to notify the anesthesiologist?
- patient's:
- -change in CMST
- -confusion
- -continued dizziness
- -nausea
- -increased heart rate/lightheadness with decrease in BP
- -problem with catheter line
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What should the nurse do if the catheter becomes disconnected or sterility is compromised?
- 1. turn off pump
- 2. cover end of catheter with a sterile cap
- 3. DO NOT reconnect catheter
- 4. keep catheter intact
- 5. call anesthesiologist
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Is it okay for epidural to be used in pediatric population?
- OK for all ages
- dose is per kg
- requires continuous cardiac, respiratory, and O2 stat monitoring
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If an elder patient has an epidural what should the nurse be aware of?
hypotension especially if patient is taking antihypertensives
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For PCA & Epidural administration what is important for the nurse to understand?
- They provide acute pain control
- how to administer correct medication dosage
- interpret orders
- knowing the equipment
- assessing patient for pain and side effects
- teaching patient how to use PCA
- DOCUMENTING
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