1. PCA, Glasgow Coma Scale, Canadian Neurological Stroke Scale

2. Patient controlled Analgesia
Breaks the pain cycle
Gives the control to the patient (often using less narcotic)
Avoids peaks and valleys
Decreases chance of errors
Decreases nursing workload
Manages acute and chronic pain, effective with operative procedures, trauma, and cancer treatment

3. Mechanics of the various systems of PCA
RN programs pump according to Dr’s orders in dose increments( 2 nurse check)
Minimum interval between doses (lock out period)
Client initiates dose by pressing hand held button
IV is tkvo or at a regular rate
Usually morphine/ fentanyl/ demerol
Lock out period prevents another dose being administered during that period of time, safegard to limit possibility of over medications
Consists of portable infusion pump with a reservoir for a prefilled syringe with prescribed opiod
Health teaching done to ensure patient understands instructions
***Narcan handy in case of respiratory depression

4. Who is a candidate for PCA?
Must need parenteral meds
Must have a willingness to operate pump
Mentally alert and competent
Able to follow instructions
Although some texts say otherwise, the patient is the only person who should be operating the pump. If the patient can’t, they really are not a candidate.
Advantages: 1. consistent analgesic level 2.patient is in charge of their own pain management 3. less medication tends to be used 4. patient is more satisfied with improved pain relief

5. who Isn’t
Patients with chronic pulmonary disease (predisposition to respiratory depression)
History of drug abuse
Major psychiatric disorders
Children (some)
Some elderly etc

6. roles RPN Role: Assessment
Documentation (pca assessment and sedation score)
Reporting tolerance
& changes, + & -
RN role:
Program pump
Ongoing assessment
Documentation
Maintenance of medication syringes in the pump
Usually each institution has its own required documentation. Make sure you are aware what it is and how it is done

7. Assessment Baseline vital signs Ongoing comparison to baseline
Allergies
Assess pain and sedation level
Volume delivered and attempts made
Can teach patient and family to monitor pain intensity, quality and duration.
Must monitor resp rate and BP
Must teach how to use the pca device
Assess responsiveness to pain control

8. Teaching Usually done pre-op so the patient understands how it works
Should provide both written and verbal instructions (how to notify staff if inadequate control, change in pain intensity, machine malfunction, alarms

9. Pain Team
Usually comprised of and RN/Nurse Practitioner with Pain Management training
MD- usually an Anesthetist

10. Neuro assessments -CVA
To assess state of neurological impairment & pick up subtle changes
Pupillary Response :
Mentation:
Motor Function: Expressive or Receptive
Vital Signs
*refer to handouts- Canadian Neurological Stroke Scale and Neurological Observation Record

11. Pupillary response Size Shape Reaction to light
Ability to move together
Equal bilaterally?

12. Mentation LOC alert/drowsy Orientation oriented/disoriented
Speech normal
receptive deficit- unable to understand
written or spoken words
expressive deficit – understands but unable to write or speak effectively

13. Motor Function-Expressive
Face smile
Arm proximal
Arm distal
Leg proximal
Leg distal

14. Motor Function-Receptive
Face mimic grin or watch expression
with pressure to sternum
Arms place arms 90
Legs place thighs toward body

15. Vital Signs Assess resp. watch for cheyne-stokes, rate and rhythm
Watch for widening pulse pressure(difference between systolic and diastolic pressure)
Can signifiy increased Intrcranial Pressure or ICP

16. Glasgow Coma Scale
Assess depth and duration of coma & impaired consciousness
Used for acute brain injury D/T:
-traumatic injury
-vascular injury
-infections
-metabolic disorders(hypoglycemia, renal failure, ketoacidosis, hepatic failure)

17. Glasgow coma scale

18. Head Injury Classification (GCS)
COMA: No eye opening, No ability to follow commands,No word verbalizations
Death less than 3
Severe H I to 8
Moderate H I to 12
Mild H I to 15
Normal

19. Learning activities
Complete Neurological Stroke Scale on your partner and switch
Complete Glasgow Coma Scale on your partner and switch