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N206 > Epidural/PCA > Flashcards

Epidural/PCA Flashcards

1
Q

When a patient is taking acute pain modality like PCA or Epidural, who is the only person who may order opioids, sedatives, benzodiazepines, and NSAIDS?

A

Only the anesthetist

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2
Q

What is patient controlled analgesia?

A

a method of pain relief that involves a locked, electronic infusion device that is programmed to allow a preset medication does to be administered by the patient by pressing a control button

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3
Q

What are the three routes of administration for PCA?

A

IV (most common in surgical)
SC (most common in palliative)
Epidural (less common esp in Canada)

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4
Q

What principal of pain does PCA best use?

A

Pain is what the pt says it is and when it says it is

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5
Q

What severity of pain is PCA used for?

A

moderate to severe

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6
Q

What are some common PCA medications?

A

morphine
hydromorphone
fentanyl
demerol

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7
Q

How long can Demerol be used for, why?

A

72 hours because it causes build up of metabolites which can cause seizures.

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8
Q

Is PCA ever given dry?

A

no, it is always accompanied by a continuous IV

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9
Q

What items are needed for the physical setup for PCA?

A 
IV pump and pole
PCA machine
PCA tubing
Syringe/bag with medication
Running IV solution
PCA pre printed orders
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10
Q

What is the PCA dose or demand dose?

A

the dose that the pt receives each time they push the button

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11
Q

What is Delay interval (Lockout Time)

A

it is the amount off time that must pass before pt can get next dose

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12
Q

What is total injections?

A

the number of injections the pt has received since the pump was last cleared

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13
Q

What are demands?

A

the total number of times the pt has pressed the button

different than number of times they have received it

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14
Q

What is the total dose (or mg injected)

A

the total medication the pt has received

may be from the start of the PCA or by shift

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15
Q

What is a loading/bolus dose

A

the nurse/dr initiated dose used at the start of PCA

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16
Q

What is the basal infusion rate? is this common?

A

It is the small amount of medication that is given in the background on top of the PCA

Not common anymore, esp in Canada

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17
Q

Who are good candidates for PCA?

A

Post op, trauma, labor and delivery, cancer and end of life pain

Chronic pain not managed with oral analgesia

must be physically and mentally capable

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18
Q

Who are poor candidates for PCA

A

the very young and old

indiviuduals with asthma, obesity, sleep apnea (things that inhibit/affect the respiratory system) or concurrent drugs that potentiate opioids

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19
Q

List 9 advantages of PCA

A

1) pt directed, prompt/on demand
2) independent of nurse (no bias)
3) individualized
4) reduces analgesic peaks/valleys
5) dec amount of opioid consumption when compared with intermittent dosing
6) fewer side effects
7) inc client control; dec client anxiety
8) fewer post op complications
9) BETTER pain control

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20
Q

What is the biggest and most important advantage of PCA?

A

Better pain control with the lowest amount of medication

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21
Q

What is one of the things that is difficult for PCA?

A

the specific guidelines for care that include frequent assessments etc

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22
Q

list the 11 things that MUST be assessed regarding PCA

A

1) PCA settings
2) Total dose delivered
3) Number of times pump was activated (number received and number of demands)
4) Sedation level
5) Level of cognition
6) Analgesia level
7) Respiratory assessment
8) Vital signs
9) IV site and pump
10) Effectiveness
11) Side effects

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23
Q

What are the four classes of complications r/t PCA, include some examples

A

DRUG RELATED: overdose, ae

CLIENT RELATED: not pushing it enough, pt is too drowsy, family or HCA pressing button (this inc risk of respiratory depression)

PUMP RELATED: failures, battery dying

OPERATOR ERRORS: incorrect programming

24
Q

List 7 points that should be touched on in patient teaching regarding PCA

A

1) Assure pt about the safety of the system
2) speak to fear of addiction/overdose
3) teach pt when to use PCA 4) teach pt how to use PCA
5) ONLY pt may use button
6) teach pt to report side effects
7) encourage pt to ask questions about PCA

25
Q

What should you tell the patient about when to use the PCA?

A

Make sure that they understand it is not about watching the clock

(emphasize pressing it whenever they feel pain going above the acceptable lvl and press it as soon as it does and to anticipate when they will experience (ex mobilizing))

26
Q

What can we do if the PCA is ineffective? (5)

A

1) assess pump usage
2) increase the PCA dose or dec lockout interval as prescribed and reassess
3) additional multi-modal medications (remember ATC dosage, adjuvants, may need to advocate)
4) Notify APS (acute pain services)
5) Assess for possible surgical complications (ex compartment syndrome)

27
Q

Discuss some safety considerations for PCA. (5)

A

1) careful programming of the pump
2) only pt may use PCA button
3) use PCA specific tubing and PCA dedicated pump
4) medication compatibility with the opioid
5) do not give other opioids unless ordered or authorized by anesthesia provider

28
Q

What is epidural analgesia/anesthesia?

A

injection or infusion of opioid analgesics and or local anesthetics into the epidural space

may be intermittent or continuous.

29
Q

List the three layers that cover the brain and spinal cord from outer to inner

A

Dura mater
Arachnoid mater
Pia mater

30
Q

Where is the CSF found?

A

in the subarachnoid space

31
Q

Where does the spinal cord end?

A

L1

32
Q

Where are the lumbar epidurals done?

A

before the level of L2

33
Q

what is a dermatome?

A

an area of skin innervated by a single spinal route

34
Q

Where is the epidural administered? Is there fluid in this space?

A

outside the dura mater

no fluid in this region

35
Q

where is the epidural catheter inserted?

A

into thoracic or lumbar region

36
Q

What position does the patient need to be in to have an epidural?

A

fetal or tucked position

37
Q

When an epidural is inserted into the lumbar region, where is it inserted?

A

L2-3 or L3-4

38
Q

Is an epidural catheter taped or sutured?

A

taped

39
Q

Does an epidural catheter need flushing?

A

no because there is no fluid in the epidural space

40
Q

Explain how opioid epidurals work

A
  • diffuse into the subarachnoid space
  • bind to opioid receptors in the spinal cord
  • block the transmission of pain impulses to cerebral cortex
41
Q

what are common epidural drugs?

A

morphine, fentanyl, and hydromorphone

42
Q

What type of drugs act faster in epidurals?

A

Lipid soluble drugs act faster than less lipid soluble drugs because it goes through a fat layer.

43
Q

How do local anesthetics work in epidurals?

A
  • alter conduction of nerve impulses by blocking sodium channels on the nerve membrane
  • some nerve fibres more sensitive then others; size of nerve fibre and amount of myelin sheath determine its sensitivity
44
Q

What are some commonly used local anesthetics used in epidurals?

A

bupivacaine and ropivicaine

45
Q

Which type of epidural are dermatomes important for?

A

local anaesthetics since opioids do not block sensation

46
Q

Describe the sequence of loss of nerve function for local anesthetic epidural

A

1) Sympathetic response -> dilation of skin and blood vessels
2) pain/temperature recognition
3) touch/pressure
4) proprioception
5) motor function

functions return in reverse order

47
Q

List 6 advantages of epidural analgesia

A

1) eliminates peaks and valleys when compared with intermittent IM or IV
2) less drug needed for effect
3) fewer side effects (very localized)
4) better pain control which increases mobility and improves resp effort
5) better compliance with recovery activities
6) dec length of stay

48
Q

list 3 target epidural populations

A

post op pain

labor and delivery

long term pain control

49
Q

list 6 contraindications for epidurals

A

1) bleeding disorders or anticoagulation
2) site issues
3) sepsis
4) utero-placental insufficiency in antepartum patient (inadequate placental flow)
5) patient refusal
6) uncorrected hypovolemia

50
Q

what is the nurse’s responsibility r/t to epidural analgesia

A

assist with insertion, maintenance, physical and emotional support, may discontinue

51
Q

list 4 do nots of epidural catheters

A

DO NOT….

disconnect epidural port from catheter

inject any solution into the epidural catheter

remove the dressing over the insertion site on lower back

flush epidural catheter

52
Q

list the 6 things that must be assessed with epidural analgesia

A

1) vital signs
2) analgesia scale
3) sedation skill
4) respiratory system
5) sensory level (if local anesthetic) - dermatomes
6) motor power (if local anesthetic) - block assessed by ability to flex

53
Q

how do you manage ineffective analgesia?

A

1) breakthrough analgesia
2) assess dermatomes to see if it is working
3) reposition pt
4) check catheter and insertion site
5) inc infusion rate
6) optimize multimodal medications
7) notify APS or anesthesia

54
Q

list the six potential complications of epidural therapy

A

1) post dural puncture headache
2) infection
3) EPIDURAL HEMATOMA
4) local anesthetic toxicity
5) local anesthetic toxicity
6) catheter occlusion or dislodgement
7) accidental disconnection

55
Q

Explain what a post dural puncture headache is.

A

It is a headache that occurs 24-48 hrs after insertion.

only occurs if dura or arachnoid membrane is punctured resulting in CSF leak

Tx is bed rest, analgesic, sometimes IV.

usually resolves on own, but if does not, may infuse blood to cause a clot

N206 (1 decks)

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