# Situation: A 48-year-old woman weighing 60 kg returns to the surgical ward after an open abdominal operation under general anesthesia. She has an indwelling urinary catheter and a wound drain. Her preoperative blood pressure was 126/80 mmHg and her heart rate was 80/min. Her daughter stays with her as a watcher. On the first postoperative day she has morphine by patient-controlled analgesia (PCA). The nurse sees her daughter pressing the button while the client sleeps "so she will not wake up in pain." What should the nurse do?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 48-year-old woman weighing 60 kg returns to the surgical ward after an open abdominal operation under general anesthesia. She has an indwelling urinary catheter and a wound drain. Her preoperative blood pressure was 126/80 mmHg and her heart rate was 80/min. Her daughter stays with her as a watcher.

On the first postoperative day she has morphine by patient-controlled analgesia (PCA). The nurse sees her daughter pressing the button while the client sleeps "so she will not wake up in pain." What should the nurse do?

## 보기

1. Allow it, since the pump's lockout interval prevents overdose
2. Tell the daughter to press it only when her mother moans
3. Explain that only her mother should press the button **✔ 정답**
4. Ask the physician to add a continuous background infusion

**정답: 3**

## 해설

Patient-controlled analgesia is safe because a client who becomes too drowsy stops pressing the button. When a family member or staff presses it (PCA by proxy), this safeguard is lost and overdose with respiratory depression can occur. Watchers should be included in teaching and told that only the client operates the button.

## 심화 해설

The core safety mechanism of patient-controlled analgesia (PCA) rests on the patient’s own level of consciousness. When a client becomes overly sedated, she stops pressing the button, which naturally limits further opioid delivery. If another person presses the button on behalf of a sleeping patient, this built-in safeguard disappears, and the risk of opioid overdose with respiratory depression rises sharply. In this situation, the daughter is performing unauthorized PCA by proxy, and the nurse’s priority is to stop that practice and re-educate the family member.

Watch out! The lockout interval on a PCA pump prevents rapid repeated self-dosing, but it does not make the device safe when someone else presses the button. A proxy can deliver a dose during a vulnerable period, such as when the patient is already sedated or has a falling respiratory rate, and the lockout will not detect that clinical danger.

The American Society for Pain Management Nursing explicitly states that PCA by proxy is not supported because it removes the patient’s own level of alertness from the safety equation. The organization does allow a separate, carefully regulated practice called Authorized Agent Controlled Analgesia (AACA), but only when the facility has clear written guidelines, defined patient selection criteria, and close monitoring protocols in place [1]. This case does not describe such a program; it describes a family member acting on her own.

The distinction matters clinically. In AACA, the authorized agent is usually a trained nurse or a designated caregiver operating under a specific order and monitoring plan, often for patients who cannot use the button themselves because of age, neuromuscular limitation, or terminal illness [2][3]. That is not the same as a family member pressing the button while the patient sleeps. Even in pediatric oncology settings where proxy PCA has been studied, it was implemented with structured selection criteria and monitoring, not as an informal bedside decision [3].

The daughter’s intention is understandable, but the nurse must correct the behavior immediately and provide teaching. The explanation should be direct: only the mother should press the button, because her own drowsiness is the signal that tells the pump to stop delivering more opioid. If the mother is asleep and not in visible distress, she does not need a dose. If she wakes and reports pain, she can press the button herself.

| Option | Why it is incorrect | Safety concern |
| --- | --- | --- |
| 1. Allow it, since the lockout interval prevents overdose | The lockout prevents rapid repeated dosing, not overdose from a proxy pressing during sedation | Respiratory depression can still occur |
| 2. Tell the daughter to press it only when her mother moans | Moaning is not a reliable indicator of pain or of safe opioid delivery; a sleeping patient may moan without needing a dose | Still constitutes PCA by proxy |
| 4. Ask the physician to add a continuous background infusion | A basal infusion removes even more of the patient’s control and increases opioid exposure during sleep | Higher risk of oversedation and respiratory depression |

Key point! The correct nursing action is to explain that only the mother should press the button. Family education is an essential part of PCA safety, and watchers must understand that helping by pressing the button actually increases the danger rather than reducing it [1]. If the patient is unable to operate the PCA button because of sedation, weakness, or cognitive limitation, the appropriate next step is a formal reassessment of the pain management plan, not informal proxy dosing by a family member.References (research sources)

- [1]Authorized and Unauthorized ("PCA by Proxy") Dosing of Analgesic Infusion Pumps: position statement with clinical practice recommendations.GuidelineWuhrman E, Cooney MF, Dunwoody CJ, Eksterowicz N, Merkel S, Oakes LL (2007) · DOI: 10.1016/j.pmn.2007.01.002

- [2]PCA by proxy: taking the patient out of patient-controlled analgesia: this controversial practice can be done safely in carefully controlled circumstances.Research articleD'Arcy Y (2013) · DOI: 10.1097/DCC.0b013e31829d3bff

- [3]The safety of patient-controlled analgesia by proxy in pediatric oncology patients.Research articleAnghelescu DL, Burgoyne LL, Oakes LL, Wallace DA (2005) · DOI: 10.1213/01.ANE.0000184198.13285.33

## 임상 시나리오

PCA by Proxy: Stop and Re-EducateOnly the patient presses the button
The safety of patient-controlled analgesia depends on the patient's own level of consciousness. When a patient becomes too drowsy, she stops pressing the button, which naturally limits opioid delivery.

If a family member presses the button while the patient sleeps, this safeguard is lost. The risk of opioid overdose with respiratory depression rises sharply. The nurse's priority is to stop the PCA by proxy immediately and re-educate the daughter.

CautionThe lockout interval prevents rapid repeated self-dosing, but it does not make the device safe when someone else presses the button. A proxy can deliver a dose when the patient is already sedated or has a falling respiratory rate.

## 핵심 개념

- **PCA by proxy** — When someone other than the patient presses the PCA button, bypassing the sedation-based safety mechanism and increasing overdose risk
- **Lockout interval** — The minimum time between PCA doses that prevents rapid self-dosing but does not make proxy dosing safe
- **Respiratory depression** — A serious opioid adverse effect of slow, shallow breathing that can progress to apnea and death
- **Authorized Agent Controlled Analgesia** — A regulated practice where a trained agent delivers PCA doses under strict protocols, distinct from unauthorized family proxy dosing

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