PCA NURSING MANAGEMENT

Patient Controlled Analgesia (PCA) is effective for pain management and can be used in many settings so it is
essential for nurses who are caring for patients using PCA to be educated on its use and potential complications.

Pain is a highly subjective experience. It can be impacted by biological, psychological and social experiences and
therefore is extremely personalised to the individual. Pain is a common occurrence and can be quite debilitating
for the person experiencing it. An accurate pain assessment is needed in order to provide effective pain
management.

Because pain is a very subjective experience, the best measure of pain is a valid self-report of the pain. Patients can
indicate pain in a number of ways including verbal reports on pain and non-verbal cues including grimacing.

Therefore, an effective pain assessment relies on communication between the nurse and the patient.

When assessing an individual’s pain, the following guideline may be used:

 A history of the present pain

 Onset and duration
 Location
 Quality and characteristics
 Intensity
 Aggravating or relieving factors
 Use of pain assessment tools
 Associated physical effects
 Patient factors such as knowledge, expectations and preferences for pain management.

Pain should be assessed on movement as well as at rest and always remember to evaluate any pain management
strategies used.

PCA

Patient Controlled Analgesia (PCA) is a method of pain control designed to allow the patient to administer pre set
doses of an analgesic, on demand (APS, 2003). Although the medications may be delivered via any route, for the
purpose of this position statement, the term refers to medications which are administered using an analgesic
infusion pump.

Analgesic infusion pump (often referred to as PCA pump) is an electronic micro processing machine which can be
programmed to deliver a prescribed amount of medication on demand, at specified intervals, by activation
(pressing) of a button. It also has the programming options to deliver patient boluses along with a continuous
infusion, or a continuous infusion without patient boluses (thus contradicting the term “ PCA” pump.) It can also be
used to deliver supplemental clinician “boluses” or “loading” doses of medication.

Authorized Agent Controlled Analgesia (AACA) is a method of pain control in which a consistently available and
competent individual is authorized by a prescriber and properly educated to activate the dosing button of an
analgesic infusion pump when a patient is unable, in response to that patient’s pain.

 Nurse Controlled Analgesia (NCA): the authorized agent is the nurse responsible for the patient.
 Caregiver Controlled Analgesia (CCA): the authorized agent is a nonprofessional individual (e.g. parent,
significant other)

Patient-Controlled Analgesia Pump

A patient-controlled analgesia (PCA) pump is a computerized machine that releases a drug for pain at the press of a
button.

What is the patient-controlled analgesia pump?

The patient-controlled analgesia (PCA) pump is a computerized machine that gives the patient a drug for pain
when they press a button. In most cases, PCA pumps supply opioid pain-controlling drugs such as morphine,
fentanyl, and hydromorphone. The pump is attached to a thin, flexible tube (intravenous or I.V. line) that is placed
in their vein. This medicine may be delivered either continuously (basal rate) or only when they press the button
(bolus).

What to know about the patient-controlled analgesia pump?

The health care provider will set controls on the pump, which will be programmed for the pain-relieving drug that
the doctor orders. The PCA pump is safe to use because the patient receives medication by pressing the button
when they feel pain, but the pump will not give them the drug if it is not time yet. Remember, no one should press
the button on the PCA pump except for the patient. The only time another (authorized) person is allowed to use
the pump is if the setup is an AACA. When the pump is empty, an alarm will let the nursing staff know.

How often should the patient-controlled analgesia pump be used?

The patient can use the pump whenever they feel pain. If they are feeling sleepy, they should not push the button.
The goal of the pump is to keep their pain at a level they can tolerate.

What are the benefits of a patient-controlled analgesia pump?

People who use the pumps often use less of a pain drug and are less tired as a result. People who are less tired
move around more; cutting down on the risk of blood clots after surgery. Also, patients feel less anxiety and can
relax if they feel like they can better control their pain.

What are the side effects of opioid drugs?

Some common side effects of opioid drugs for pain include:

 Upset stomach
 Vomiting
 Nausea
 Drowsiness
 Itching
 Dry mouth
 Being unable to make a bowel movement (constipation)
 Slowed breathing

Less common side effects may include having stiff muscles and being more sensitive to pain. Doctors may need to
change the patient’s medicine or dosage to help stop the symptoms.

Nursing Interventions & Education

It is important to avoid playing catch-up when initiating PCA. Pain should be brought under control before PCA is
initiated. This may require an initial or larger bolus dose. When patients with severe pain have low serum levels of
opiates, it is difficult to regain control with the small doses given through the pump.

Patients should be instructed not to wait until the pain becomes severe before pushing the button for a medication
dose. This includes not becoming distracted by activities or visitors so that when the distraction ends, pain will
return and he will need to “play catch up.”4 Patients should be assured the use of opiates rarely results in
addiction (1-3 percent), and the benefits of proper pain management clearly outweigh the complication of
immobility, hypercoagulability and activation of the stress response.

Many surgical patients do not receive teaching about the pump or use the pump until after surgery. The ideal time
to educate patients and demonstrate the pump is preoperatively. If teaching is done with family members present-
emphasize clearly that only the patient is to activate the pump to prevent dangerous overdose.

As always, nurses should include non-pharmacologic interventions for pain. Massage, repositioning, ice or heat can
be used as adjuncts to pain management. Distraction may be useful; however, a patient in severe pain may be
unable to concentrate on complex mental activities.

Nurses will:

 Follow established policy for the care of patients receiving PCA and AACA .
 Educate patients, family members, and other visitors about the purpose and proper use of analgesic pumps,
including pump safety features and the dangers of unauthorized activation of the dosing button.
 Participate in the selection of authorized agents by assessing the willingness and abilities of the patient’s
caregiver or significant other to understand AACA and follow instructions.
 Provide and document that the authorized agent has received, reviewed, and applied verbal and written
instructions which include, but are not limited to, the following:
 How to recognize specific patient behaviors or circumstances that may indicate the need for
analgesia
 How to activate the analgesic dosing button
 How to recognize patient specific indicators that would preclude activating the dosing button at
a given time (e.g. sedation, shallow or irregular respirations). Such indicators require definition
by prescription for each particular patient
 Appropriate actions to take in the event of pump malfunction, unrelieved pain, excessive side
effects or other such medical emergencies, and any other conditions the health care agency
and/or particular prescriber specifies
  Information that activation of the dosing button should only occur if the patient is awake and/or
the patient’s words or behaviors indicate to the authorized agent that the patient is in pain or
pain is anticipated (incidental pain), unless otherwise specified by the prescriber, such as in the
case of the unresponsive and/or end of life patient
 When not to activate the dosing button, such as:
 For purposes other than pain relief (e.g., not for the purposes of having the patient
sleep or to become less anxious)
 While the patient is sleeping
 If the patient cannot be readily awakened to baseline
 If the patient is having abnormal breathing, as defined by prescriber (shallow, slow, or
noisy)
 How to recognize pain, sedation, and respiratory depression
 What to do if an emergency situation arises (e.g., stimulates the patient, notify nurse, or call 911
in the home setting). Include emergency numbers as appropriate.
 Continually assess the ability of the caregiver to provide AACA. If the nurse has any concerns regarding a
caregiver’s ability to administer AACA, the nurse must stop the caregiver from activating any further doses,
inform the prescriber of the situation, and obtain an order for an alternative means of pain relief.
 Provide a complete report of the patient’s tolerance of AACA, including the authorized agent’s performance,
when the care of the patient is being transferred to another nurse.
 Communicate to all other health care providers that the patient is receiving AACA (e.g. chart, bed, or analgesic
infusion pump/button label or sign).

Checklist for Nursing Management for PCA

Demonstrates awareness of Infection Control and OH&S (Occupation Health & Safety) requirements
1. Wash hands
2. Position self
3. Ensure patient comfort
4. Don PPE
5. Dispose of equipment

Demonstrates communication and interpersonal skills

1. Address patient by name
2. Explain procedures
3. Respond to needs
 4. Complete documentation
5. Reinforce PCA education

Demonstrates safe practice

1. Read PCA prescription
2. Adhere to the hospital policies related to PCA management
3. Identify patient
4. Do not leave medication unattended
5. Check for known drug allergy
6. Assess patency of IV or SC cannula
7. Observe patients for any adverse drug reaction

Set up
1. Gather equipment
2. Prepare medication
3. Label prepared syringe
4. Adhere to the 5 rights of medication administration
5. Prime the line and antireflux valve
6. Connect to the patient

Programming of the PCA pump

1. Confirm programming with a second RN
2. Select protocol
3. Modify protocol as required
4. Confirm all program parameters
5. Commence PCA
6. Hand button to patient

Syringe change
1. Gather equipment
2. Prepare medication
3. Label prepared syringe
4. Adhere to the 5 rights of medication administration
5. With second RN, change syringe
 6. Discard remaining drug volume
7. Reconfirm all program parameters with second RN

Records observations
1. Record observations
2. Determine pain score at rest and on movement and takes remedial action
3. Assess respiratory rate and takes remedial action
4. Determine oxygen saturation
5. Assess sedation score and takes remedial action
6. Assess for complication and take remedial action
7. Record demands made and successful doses received
8. Record amount remaining in syringe
9. Record cumulative total of drug delivered
10. Record current infusion rate, if applicable
11. Check patients understanding of PCA use

Video Links:
1. Patient Controlled Analgaesia (PCA): Skills video QUT School of Nursing
https://www.youtube.com/watch?v=lHR0yz7z4Oo&ab_channel=HelenDonovan

2. Patient Controlled Analgesia

https://www.youtube.com/watch?v=9iXH0X8PsTY&ab_channel=CHEO

3. PCA Setup Part 1

https://www.youtube.com/watch?v=RtWjHQNwu8&ab_channel=ColumbiaGorgeCommunityCollege

4. PCA Setup Part 2

https://www.youtube.com/watch?v=kXaMW754Hk4&ab_channel=ColumbiaGorgeCommunityCollege

5. PCA Initiation
https://www.youtube.com/watch?v=GDIoo___tkg&ab_channel=ColumbiaGorgeCommunityCollege