A nurse is caring for an adult client after major abdominal surgery who is using an opioid patient-controlled analgesia (PCA) pump. Which actions promote safe PCA use? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Only the client presses the demand button; sedation that prevents button use is an important safety brake (Choice 5). PCA by proxy defeats that safeguard (Choice 3). Monitor sedation, respiration, and oxygenation according to risk and protocol, holding medication and escalating for respiratory depression (Choice 2). Keep naloxone accessible and assess risk factors (Choice 1). Basal-rate changes require an order (Choice 6). Follow facility policy for independent verification of the high-alert opioid, concentration, and pump settings rather than relying only on software or a single unchecked setup (Choice 4).
PCA Core Safety Principle ONLY the client presses the demand button. If sedation reaches a level where the client cannot press, the system stops itself — built-in protection.
PCA by Proxy = NEVER - Family/visitor pressing the button defeats the safety mechanism - Leading cause of fatal opioid-induced respiratory depression on PCA - Educate family and place a "PCA by proxy: Do Not Press" sign at bedside
Monitoring 1. Respiratory rate q1-2h initially 2. Sedation level (POSS — Pasero Opioid-induced Sedation Scale) 3. SpO2 continuous if high risk; capnography preferred 4. Hold opioid if RR <8/min or POSS 3-4 (frequent drowsiness or unarousable) 5. Naloxone readily available
High-Alert Medication Safeguards - Two-RN independent verification: pump settings, drug, concentration, dose, lockout — at start of shift, bag change, rate change - Smart pump with drug library - Document programming
Risk Factors for Respiratory Depression Older age, opioid-naive, OSA, BMI >30, concurrent CNS depressants, renal/hepatic impairment, post-major-surgery first 24 hr
ScenarioAdult client, post major abdominal surgery, on opioid PCA pump. Family is present; client may be opioid-naive.
Safe PCA Care Bundle1. Only client presses; family education + bedside sign2. Two-RN independent verification of pump program at start, bag/rate change3. RR + sedation (POSS) + SpO2 monitoring4. Hold + notify: RR <8/min, deepening sedation5. Naloxone readily available6. Risk factor assessment
Avoid- PCA by proxy- Independent basal rate increase by nurse- Single-RN verification of opioid program
PCA Pump (Patient-Controlled Analgesia) — Programmable infusion pump that allows the client to self-administer a preset bolus dose of an opioid (commonly morphine, hydromorphone, fentanyl) within prescribed limits. Components: demand dose, lockout interval (5-10 min typical), 1-hour or 4-hour dose limit, optional basal continuous rate. Safety relies on the principle that only the client presses; when sedation impairs ability to press, dosing pauses.
PCA by Proxy (Safety Hazard) — Anyone other than the client (family member, visitor, or staff member acting at the request of the family) pressing the demand button. Defeats the built-in sedation-driven safety mechanism and is a leading cause of fatal opioid-induced respiratory depression on PCA. Strictly prohibited; nurses must teach the family explicitly and post a warning sign at the bedside. Authorized agent-controlled analgesia (AACA) programs in pediatrics or end-of-life care are a separate, formally authorized, and closely monitored exception.
Opioid-Induced Respiratory Depression Monitoring — Use a validated sedation scale (e.g., Pasero Opioid-induced Sedation Scale — POSS: 1=awake/alert, 2=slightly drowsy/easy to arouse, 3=frequently drowsy/arousable but drifts off mid-conversation, 4=somnolent/minimal/no response). Hold opioid and notify provider for POSS 3-4 or RR <8/min. Risk factors: older age, opioid-naive, OSA, BMI >30, concurrent benzodiazepines or other CNS depressants, renal/hepatic impairment, post-major-surgery first 24 hours. Continuous capnography is the most sensitive monitor and is preferred for high-risk clients.