PCA, Glasgow Coma Scale, Canadian Neurological Stroke Scale

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

Glasgow coma scale

Head Injury Classification (GCS) COMA: No eye opening, No ability to follow commands,No word verbalizations Death less than 3 Severe H I 3 to 8 Moderate H I 9 to 12 Mild H I 13 to 15 Normal 15

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