CHAPTER 46 / Pain Management 1217

Primary (maintenance)IV fluid

PCA pump

Y-connector sitefor PCA tubing andprimary line

Figure 46-12 ■ PCA line introduced into the injection port of a primaryline.

client to maintain a more constant level of relief yet need lessmedication for pain relief. Patient-controlled analgesias can be ef-fectively used for clients with acute pain related to a surgical in-cision, traumatic injury, or labor and delivery, and for chronicpain as with cancer.

In some settings PCAs are used even if the client is unable toinitiate a dose by pushing the button, as long as a caregiver is will-ing to accept the responsibility (for example, when the client is aninfant or toddler or is physically or cognitively impaired). This hasbeen termed PCA by proxy and has been the subject of concern forthe client’s safety. In December 2004, the Joint Commission onAccreditation of Healthcare Organizations (JCAHO) published“sentinel events” pointing toward serious toxic reactions, evendeaths associated with this practice. Fifteen of 460 PCA-relateddeaths in America were directly related to this practice. In general,in the absence of a strict protocol and vigilant monitoring, thispractice should be avoided, with even stronger recommendationsto prohibit this practice (JCAHO, 2004).

The prescriber orders the analgesic dose, route, and fre-quency, with the client administering the medication. Whetherin an acute hospital setting, an ambulatory clinic, or with homecare, the nurse is responsible for the initial instruction regardinguse of the PCA and for the ongoing monitoring of the therapy.The client’s pain, ability to understand, and use of the devicemust be assessed at regular intervals, and analgesic use is doc-umented in the client’s record.

Patient-controlled analgesia pumps are designed with built-insafety mechanisms to prevent client overdosage, abusive use, andnarcotic theft. The most significant adverse effects are respiratorydepression and hypotension; however, they occur rarely. AlthoughPCA pumps vary in design, they all have similar protective fea-tures. The line of the PCA pump, a syringe-type pump, is usuallyintroduced into the injection port of a primary IV fluid line (Figure46-12 ■). When clients want a dose of analgesic, they can push a

button attached to the infusion pump and the preset dose is deliv-ered (Figure 46-13 ■). A programmable lockout interval (usually6 to 15 minutes) follows the dose, during which an additional dosecannot be given even if the client activates the button. It is alsopossible to program the maximum dose that can be delivered overa period of hours (usually 4). Many pumps are capable of deliver-ing a basal rate (continuous infusion), with or without additionalPCA doses available.

Nonpharmacologic Pain ManagementNonpharmacologic pain management consists of a variety ofphysical, cognitive-behavioral, and lifestyle pain managementstrategies that target the body, mind, spirit, and social interac-tions (see Table 46–8). Physical modalities include cutaneous

Figure 46-13 ■ The older child is able to regulate a PCA pump.

CLIENT TEACHINGClient Self-Management of Pain

Choose a time to teach the client about pain management when thepain is controlled so that the client is able to focus on the teaching.

Teaching the client about self-management of pain can includethe following:

■ Demonstrate the operation of the PCA pump and explain thatthe client can safely push the button without fear of overmed-icating. Sometimes it helps clients who are reluctant to repeat-edly push the button to know that they must dose themselves(i.e., push the button) 5 to 10 times to receive the sameamount of medication (10 mg morphine equivalent) theywould receive in a standard “shot.”

■ Describe the use of the pain scale and encourage the client torespond in order to demonstrate understanding.

■ Explore a variety of nondrug pain relief techniques that the clientis willing to learn and use to promote pain relief and optimizefunctioning.

■ Explain to the client the need to notify staff when ambulation isdesired (e.g., for bathroom use) if applicable.

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