PCA (patient controlled analgesia) Chart – adult

Education Slide Presentation

A presentation prepared by the Pain Interest Group Nursing Issues

in association with the Agency of Clinical Innovation Pain Management Network

Please direct comments to:

March 21, 2013

Emily Edmonds Coordinator State Pain Forms

Pain Interest Group Nursing Issues CNC Acute Pain Service Blacktown Hospital

Phone: 9881 7649 Email: emily.edmonds@swahs.health.nsw.gov.au

Jenni Johnson Manager

Pain Management Network Agency for Clinical Innovation (ACI)

Phone: 9464 4636 Email: jenni.johnsons@aci.health.nsw.gov.au

OR

PCA (patient controlled analgesia) chart - adult

The PCA prescription and observation chart for adult patients has been developed by a team of experts in the field of acute pain including clinical nurse consultants, anaesthetists and pharmacy representatives.

This PCA chart is not suitable for use in paediatric patients.

Standardisation of this chart promotes best practice in prescribing, pain assessment and management of adverse effects in those patients receiving an opioid via PCA.

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Aim of this presentation:

This presentation aims to explain

how to use the chart for prescribing a PCA

how to record the administration and discard of drugs used for PCA

how to complete the clinical observations

guidelines on the management of patients receiving PCA including the management of adverse effects

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PCA chart - adult Booklet format

Prescription valid for 4 days Observation pages for 4 days

Page 1 Management guidelines

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Page 2 PCA prescription

- PCA program - Neuraxial opioid + PCA

- Naloxone prescription

Page 3 PCA drug administration

- Drug discard - Naloxone administration

Inside pages: Observation pages for up to 4 days

PCA chart - adult

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Back page: Clinical Review and

Rapid Response Criteria (Between the Flags)

Prescription page:

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Patient label and allergy adverse

reactions

PCA prescription

PCA program - Allows for 2 further

changes to the program

Record of administration of a neuraxial opioid

Prescription for naloxone OR ‘sticker affixed’ stating

existing standing order

PCA prescription:

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Below is an EXAMPLE prescription Refer to hospital PCA policy for

local guidelines on PCA prescribing

SMITH 22/4/13 PSmith

Prescriber to complete patient allergy and ADR

section in full

Handwrite patient details OR affix patient

label (First prescriber to check patient label is correct)

Private patients: require a

signature from the referring

Doctor to the Pain Service

PLEASE REFER TO YOUR LOCAL HOSPITAL POLICY FOR

PCA DRUG SOLUTIONS

PCA prescription:

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Below is an EXAMPLE prescription Refer to hospital PCA policy for

local guidelines on PCA prescribing

A PCA prescription is for one opioid only. When changing from one opioid to another, a new PCA chart must be

commenced

Morphine 60 mg NIL

IV 60 mL

22/04/13 SMITH TSmith

PCA prescription to include route, primary drug

(e.g. morphine or fentanyl), total amount in mg or

microgram and total volume

Space is provided for an additional drug to be added

if necessary

Space provided for pharmacist

reconciliation

Prescriber’s signature and printed name

PCA program:

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Below is an EXAMPLE program Refer to hospital PCA policy for

local guidelines on PCA prescribing

Morphine 1mg 1mg 1

5

mins NIL 10:00 22/04/13

2mg 2

5

mins 1mg 09:00 23/04/13

SMITH TSmith

JACK S.Jack

Morphine 1mg 1

Primary drug and concentration State: mg or

microgram per mL

Two additional rows are provided for changes to

the PCA program

PCA bolus dose (state unit of

drug and volume)

Lockout interval in minutes

Background infusion (State mg or microgram

and mL per hour)

Prescriber’s signature and

print name

Date and time

When changing from one opioid to another, a new

PCA chart must be commenced

Neuraxial opioid + PCA:

IF a dose of opioid has been administered via the spinal or epidural route during a

procedure, AND the patient is to receive a PCA, the following is to be completed

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Morphine Spinal 200

micrograms

10:00 22/04/13 SMITH TSmith

The frequency of observations (hourly for 6 hours or hourly for 12 hours)

must be determined by the medical officer who administered

the opioid dose

Naloxone prescription:

Naloxone is indicated for SEDATION SCORE 3 (difficult to rouse or unresponsive) OR

SEDATION SCORE 2 (constantly drowsy unable to stay awake) and a

RESPIRATORY RATE LESS THAN OR EQUAL TO 5 breaths per minute.

This section MUST be completed in full OR a sticker affixed which states the standing

order PRIOR to any administration of naloxone.

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Naloxone

X 4

100

micrograms IV

02/04/13 SMITH

TSmith 2 -3

minutely

Administration and discard of PCA opioid and administration of naloxone:

The fold out section includes space for the documentation of : - PCA commenced - Discard of remaining PCA opioid or drug - Naloxone administration

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PCA commenced Discard of any

remaining PCA opioid or drug

Naloxone that may have been

administered

Administration and discard of PCA drug:

IF a PCA syringe or bag is empty when the next one is

commenced, document ‘NIL’ discarded

There are 14 rows provided to record PCA

administration and discard

Any opioid or drug remaining from a

syringe or bag MUST be recorded on the

corresponding row from its administration

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10:00 22/04/13 THall SRose 20:00 22/04/13 BLoh JLucas NIL

20:00 BLoh JLucas 09:00 23/04/13 Plambert TBuckley

15 mL 22/04/13

Record of naloxone administered:

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08:30 IV 100 micrograms 02/03/13 Plambert TBuckley

08:33 IV 100 micrograms 02/03/13 Plambert TBuckley

08:36 IV 100 micrograms 02/03/13 Plambert TBuckley

08:39 IV 100 micrograms 02/03/13 Plambert TBuckley

Naloxone may only be administered when the prescription section of the PCA chart

has been completed in full OR if a standing order sticker is affixed

Clinical Review & Rapid Response Criteria:

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The back page of the PCA chart displays instructions explaining when to make a Clinical Review or a Rapid

Response.

These instructions incorporate Track and Trigger color zones (from the Between the Flags Program)

to promote the recognition of the deteriorating patient

associated with the administration of opioids

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Clinical Review Criteria:

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Rapid Response Criteria:

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PCA Management Guidelines are provided on the ‘fold-out’

front page of the PCA chart

For detailed information regarding PCA prescribing and management refer to local hospital PCA policy

or procedure

PCA can be ceased according to instructions in the medical record:

Date and time prompt provided (Check local policy for use of this prompt)

There is space provided for the contact details of your

Acute Pain Service or equivalent medical officer

who manages PCA

Observations:

The PCA chart provides observations for a maximum of 4 days.

If the PCA continues beyond 4 days, a new PCA chart must be started and

a new prescription written.

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A patient label must be affixed or details written on each page that

records observations

Documenting observations: Pain Assessment: ‘R’ for rest ‘M’ for movement

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R R

R R

R

M M R

M

M

22/04/13

Documenting observations: Sedation, respiratory rate & oxygen therapy

A sedation score or a respiratory rate in the

‘Red Zone’ requires a Rapid Response to be initiated

AND contact the Acute Pain

Service (or equivalent medical officer)

A sedation score or a respiratory rate in the

‘Yellow Zone’ requires a Clinical Review by the Acute

Pain Service (or equivalent medical officer)

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2L 2L 2L 2L 6L

NP NP NP NP FM

Oxygen Device Key shown on front PCA

Management Guidelines page

Assessments must be recorded graphically

as shown

Documenting observations: Nausea or vomiting, PCA delivery

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Ondanestron given

2

mg

10

mg

13

mg

20

mg

25

mg

JS JS JS JS TJ

1

mg

1

mg

1

mg

1

mg

NIL

2

2 10 13

30

25

13 16 25

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Nausea or vomiting assessment

Total primary PCA dose (cumulative)

Circle the unit that is being used

Background infusion rate (if in use)

Total demands / good demands (different pumps use different words to describe

how many times the button is pressed)

PCA program checked: once per shift and on patient transfer

- to ensure the pump program matches the prescription

Comments section blank for free text

Assessor’s initial

The next two slides detail the front page PCA Management Guidelines

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The standardisation of this chart promotes best practice in prescribing, pain assessment and management of adverse

effects in those patients receiving an opioid via PCA.

Comments or questions can be directed to your implementation officer or the project leaders

Emily Edmonds or Jenni Johnson (for contact details see introduction slide)

The feedback register can be located on the ACI website:

http://www.aci.health.nsw.gov.au/networks/pain-management/acute-pain-forms

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