Skill 10-4

Caring for a Patient Receiving Patient-Controlled Analgesia

Patient-controlled analgesia (PCA) allows patients to self-administer small doses of analgesic within a prescribed time interval, controlling the administration of their own medication within predetermined safety limits (Bauldoff et al., 2020). This approach can be used with oral analgesic agents as well as with infusions of opioid analgesic agents by intravenous, subcutaneous, sublingual, epidural , and perineural routes (Golembiewski et al., 2016; Katz et al., 2017). PCA provides effective individualized analgesia and comfort. This drug delivery system can be used to manage acute and chronic pain in a health care facility or the home, in a wide range of clinical situations (Nijland et al., 2019).

The PCA system used to deliver an intravenous opioid analgesic permits the patient to self-administer medication (bolus doses) with episodes of increased pain or painful activities. A timing device electronically controls the PCA pump. The PCA system consists of a computerized, portable infusion pump containing a reservoir or chamber for a syringe or other reservoir that is prefilled with the prescribed medication, usually an opioid, or dilute anesthetic solution in the case of epidural administration (D'Arcy, 2013; Hinkle et al., 2022). When pain occurs, the patient pushes a button that activates the PCA device to deliver a small, preset bolus dose of the analgesic. A dose interval that is programmed into the PCA unit prevents reactivation of the pump and administration of another dose during that period of time (bolus; commonly 6 to 8 minutes). The pump mechanism can also be programmed to deliver only a specified amount of analgesic within a given time interval (basal rate; most commonly every hour or, occasionally, every 4 hours). These safeguards limit the risk for overmedication and allow the patient to evaluate the effect of the previous dose. PCA pumps also have a locked safety system that prohibits tampering with the device (Karch, 2020; Pasero & McCaffery, 2011).

The proper selection of patients for PCA is vital for a safe, positive experience (Grissinger, 2019). Suitable candidates for this type of delivery system include people who are alert and capable of controlling the unit. The Institute for Safe Medication Practices (ISMP, 2016) identifies people for whom this type of pain relief is not recommended, including confused older adults, infants and very young children, cognitively impaired patients, patients with conditions for which oversedation poses a significant health risk (e.g., asthma and sleep apnea), and patients who are taking other medications that potentiate opioids. PCA has proven safe for use in developmentally normal children as young as 4 to 6 years of age (DiGiusto et al., 2014; Pasero & McCaffery, 2011). All patients should be assessed for level of risk of opioid-induced advancing sedation and respiratory depression; the plan of care and monitoring strategies should be driven by reassessment according to level of risk (Jungquist et al., 2020).

Nursing responsibilities for patients receiving medications via a PCA system include collaboration with the health care team and the patient to ensure appropriate patient selection criteria, patient/family/caregiver teaching, knowledge of the appropriate drugs used with PCA, initial device setup, monitoring the device to ensure proper functioning, and frequent assessment of the patient's response, including pain and discomfort control, respiratory status and sedation screening, and presence of adverse effects (Gorski et al., 2021). Box 10-1 (on page 658) outlines guidelines for safe and effective use of PCA. Additional information related to epidural infusions is discussed in Skill 10-5.

Delegation Considerations

The care related to PCA is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, specific aspects of the care related to PCA, such as monitoring the infusion and assessment of patient response, may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

PCA system, including programmable smart infusion pump device with dose error-reductions systems
Syringe (or appropriate reservoir for device) filled with prescribed medication
PCA system tubing
Antimicrobial swabs
Appropriate label for syringe and tubing, based on facility policy and procedure
Second clinician to verify medication and programmed pump information, according to facility policy
Pain assessment tool and pain scale
Electronic medication administration record (eMAR) or medication administration record (MAR)
Gloves
Additional PPE, as indicated

Assessment

Review the patient's health record and plan of care for specific instructions related to PCA therapy, including the prescribed intervention and conditions indicating the need for therapy. Check the health record for the prescribed drug, initial loading dose, dose for self-administration, and lockout interval. Check to ensure proper functioning of the unit. Assess the patient's level of consciousness and understanding of PCA therapy and the rationale for its use. Inquire about any allergies.

Review the patient's history for conditions that might contraindicate therapy, such as respiratory limitations, history of substance abuse, or psychiatric disorder. Review the patient's health record and assess for factors contributing to an increased risk for adverse effects, such as the use of a continuous basal infusion, the patient's age (older age, infant [prematurity, developmental delay, underweight, age ;1 year]), morbid obesity, upper abdominal or thoracic surgery, known or suspected sleep disorder breathing problems, preexisting pulmonary and/or cardiac disease, renal insufficiency, impaired liver function, history of smoking, concurrent use of sedating medications (Gorski et al., 2021; Jungquist et al., 2020). Determine the prescribed route for administration. Inspect the site to be used for the infusion for signs of infiltration or infection. If the route is via an IV infusion, ensure that the access is patent, and the current solution is compatible with the drug ordered.

Assess the patient's level of consciousness and vital signs. Assess the patient's pain and level of discomfort using an appropriate assessment tool and pain scale (refer to Fundamentals Review 10-1 through 10-4). Assess the characteristics of any pain, and for other symptoms that often occur with the pain, such as headache or restlessness. Ask the patient what interventions have and have not been successful in the past to promote comfort and relieve pain.

Assess the patient's vital signs. Assess the patient's respiratory status, including rate, depth, and rhythm; oxygen saturation level using pulse oximetry; and level of carbon dioxide concentration using capnography. Assess the patient's sedation score (Table 10-1). Determine the patient's response to the intervention to evaluate effectiveness and for the presence of adverse effects.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Acute pain
Risk for medication side effect
Knowledge deficiency

Outcome Identification and Planning

The expected outcome to achieve is that the patient reports increased comfort and/or decreased pain without adverse effects, oversedation, or respiratory depression. Other appropriate outcomes may include that the patient verbalizes an understanding of the reason of use of the therapy, the patient verbalizes and demonstrates an understanding of the use of the therapy, and the patient's family/caregiver verbalizes an understanding that the PCA is to be used only by the patient.

Implementation

Action	Rationale
1. Gather equipment. Check the medication prescribed against the original order in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's health status and can also be used to educate the patient about the medication.
3. Prepare the medication syringe or other reservoir for administration, based on facility policy (see Chapter 5 for additional information).	Proper preparation and administration procedures prevent errors.
4. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
5. Identify the patient.	Identifying the patient ensures that the right patient receives the intervention and helps prevent errors.
6. Show the patient/family/caregiver the device, and explain its function and the reason for use. Explain the purpose and action of the medication to the patient.	Explanation encourages patient understanding and engagement and reduces apprehension.
7. Plug the PCA device into the electrical outlet, if necessary. Check status of battery power, if appropriate.	The PCA device requires a power source (electricity or battery) to run. Most units will alarm to acknowledge a low battery state.
8. Close the door to the room or pull the bedside curtain. Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods (The Joint Commission, 2021). Refer to Chapter 5 for additional information related to medication administration.	Closing the door or pulling the curtain provides for patient privacy. Identifying the patient ensures the right patient receives the medications and helps prevent errors. The patient's room number or physical location is not used as an identifier (The Joint Commission, 2021). Replace the identification band if it is missing or inaccurate in any way.
9. Complete necessary assessments before administering medication. Assess the IV site for presence of inflammation or infiltration or other signs of complications. Check allergy bracelet or ask patient about allergies. Assess the patient's pain using an appropriate assessment tool and measurement scale (see Fundamentals Review 10-1 through 10-4).	Assessment is a prerequisite to medication administration. IV medication must be given directly into a vein for safe administration. Accurate assessment is necessary to guide treatment and relief interventions and to evaluate the effectiveness of pain control measures.
10. Check the label on the prefilled drug syringe or reservoir with the medication record and patient identification, verifying the drug, concentration, dose, and rate of infusion (Figure 1). Obtain verification of information from a second clinician, according to facility policy. Scan the bar code on the package, if required.	This action verifies that the correct drug and dosage will be administered to the correct patient. An independent double check by two clinicians is recommended prior to initiation of the PCA and when the syringe, solution container, drug, or rate is changed (Gorski et al., 2021). Confirmation of information by a second clinician helps prevent errors.
11. Scan the patient's barcode on the identification band, if required (The Joint Commission, 2021). Based on facility policy, the third check of the medication label may occur at this point. If so, read the label and recheck the label with the eMAR/MAR before administering the medications to the patient.	Scanning of the patient's barcode on identification band provides an additional check to ensure that the medication is given to the right patient. Many facilities require the third check to occur at the bedside, after identifying the patient and before administration. If facility policy directs the third check at this time, this third check ensures accuracy and helps prevent errors.
12. Connect tubing to prefilled syringe or other reservoir and place into the PCA device (Figure 2). Prime the tubing. Attach label to tubing, based on facility policy.	Doing so prepares the device to deliver the drug. Priming the tubing purges air from the tubing and reduces the risk for air embolism. Labeling tubing allows for identification of purpose of infusion, reducing confusion in the presence of multiple infusions.
13. Set the PCA device to administer the loading dose, if ordered, and then program the device based on the prescribed intervention, verifying the drug, concentration, dose, and rate of infusion, dose interval, and lockout interval (Figure 3). Obtain verification of information from a second clinician, according to facility policy.	These actions ensure that the appropriate drug dosage will be administered. An independent double check by two clinicians is recommended prior to initiation of the PCA and when the syringe, solution container, drug, or rate is changed (Gorski et al., 2021). Confirmation of information by a second clinician helps prevent errors.
14. Put on gloves. Depending on facility policy, remove the passive disinfection cap from the connection port on the IV infusion tubing or other access site, based on route of administration. Alternatively, use an antimicrobial swab to clean the connection port. Connect the PCA tubing to the patient's IV infusion line or appropriate access site, based on the specific site used. Secure the site per facility policy and procedure. Remove gloves. Perform hand hygiene. Initiate the therapy by activating the appropriate button on the pump. Lock the PCA device, per facility policy.	Gloves prevent contact with blood and body fluids. Passive disinfection caps contain an antiseptic-impregnated sponge that dispenses the antiseptic over the connector's top and threads and provides continuous disinfection of the needleless connection versus intermittent disinfection when using antimicrobial wipes (Barton, 2019; Casey et al., 2018). Venous access device entry points, end-caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent venous access device-related infection (Flynn et al., 2019; Gorski et al., 2021). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely (5 to 20 seconds) to ensure complete effectiveness (INS, 2021; Slater et al., 2018). Removal of gloves and hand hygiene prevent transmission of microorganisms. Connection and initiation are necessary to allow drug delivery to the patient. Locking the device prevents tampering with the settings.
15. Ensure the patient control (dosing button) is within the patient's reach. Attach the warning sign to the PCA control cord and/or PCA infusion device, per facility policy. Reinforce the steps for use with the patient and the need to press the button each time they need relief from pain (Figure 4).	The patient control (dosing button) must be within reach to enable patient use. Warning sign/label provides warning/reinforcement for the patient, family members/caregivers, and staff that the button is to be pressed only by the patient to reduce the risk for adverse effect (ISMP, 2016). Reinforcement of instructions promotes correct use of the device.
16. Initiate continuous capnography and/or pulse oximetry, based on facility policy.	Continuous capnography and/or pulse oximetry has been suggested for use in all patients receiving PCA opioids for early detection of opioid-induced respiratory depression; continuous capnography should be used in all patients receiving supplemental oxygen (Fazio & Firestone, 2020; Khanna et al., 2020).
17. Assess the patient's response to the medication: Assess the patient's pain at least every 4 hours or more often, as needed, based on patient's individual risk factors. Monitor vital signs, especially respiratory status, including respiratory rate, depth, and quality and oxygen saturation every 2 to 4 hours or more often, as needed, based on patient's individual risk factors and situation.	The plan of care and monitoring strategies should be driven by reassessment according to level of risk (Jungquist et al., 2020). Continued assessment at frequent intervals helps evaluate the effectiveness of the drug and reduce the risk for complications (Fazio & Firestone, 2020; Gorski et al., 2021; Jungquist et al., 2017a, 2017b).
18. Assess the patient's response to the medication: Assess the patient's sedation score (see Table 10-1) and end-tidal carbon dioxide level (capnography) at least every 4 hours or more often, as needed, based on patient's individual risk factors.	The plan of care and monitoring strategies should be driven by reassessment according to level of risk (Jungquist et al., 2020). Sedation occurs before clinically significant respiratory depression (Hall & Stanley, 2019). Respiratory depression can occur with the use of opioid analgesics (Fazio & Firestone, 2020; Hall & Stanley, 2019). Capnography provides an earlier warning of respiratory depression as compared to continuous oximetry (Casey, 2015; Gorski et al., 2021; Jungquist et al., 2017a, 2017b).
19. Assess the infusion site periodically, according to facility policy and nursing judgment. Assess the patient's use of the medication, noting number of attempts and number of doses delivered. Replace the drug syringe when it is empty.	Continued assessment of the infusion site is necessary for early detection of problems (Gorski et al., 2021). Continued assessment of the patient's use of medication and effect is necessary to ensure adequate pain control without adverse effect. Replacing the syringe ensures continued drug delivery.
20. Make sure the patient control (dosing button) is within the patient's reach.	Easy access to the control is essential for the patients to use the device.
21. Remove gloves and additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when the patient reports increased comfort and/or decreased pain without adverse effects, oversedation, and respiratory depression; the patient displays an understanding of use of the therapy and the reason for its use; and the patient's family/caregiver verbalizes an understanding that the PCA is to be used only by the patient.

Documentation

Guidelines

Document the date and time PCA therapy was initiated, initial assessments, drug and loading dose administered, if appropriate, and individual dosing and time interval. Document patient teaching and patient's response. Document continued pain, sedation level, vital signs and assessments, and patient's response to therapy.

Sample Documentation

6/1/25

0645 Patient returned from surgery with PCA therapy with morphine sulfate 1 mg/mL in place via IV infusion. Device programmed to deliver 0.1 mg at 10-minute lockout intervals. Patient reports moderate to severe abdominal pain, rating pain as 6 to 8/10 on a pain-rating scale. Patient instructed to press PCA button for pain relief. Vital signs within acceptable parameters. Respiratory rate 16 breaths/min, regular rhythm and depth. Oxygen saturation 96%; partial pressure end-tidal CO₂ (PetCO₂) 36%. IV of 1,000 mL D5LR infusing at 100 mL/min; IV site clean and dry without evidence of infiltration or infection.

—P. Joyner, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

While receiving PCA therapy, the patient's respiratory rate drops to 10 breaths/min, with a sedation score of 3 via sedation scale (Pasero Opioid-Induced Sedation Scale [POSS]): Stop the PCA infusion if basal infusion is present. Notify the health care team. Discontinue the basal infusion; if no basal infusion is being used, then reduce the medication dosage. Increase the frequency of sedation and respiratory rate monitoring to every 15 minutes. Arouse the patient every 15 minutes and encourage deep breathing (Jungquist et al., 2017a; Pasero & McCaffery, 2011).
While receiving PCA therapy, the patient is somnolent, with a sedation score of 4 via sedation scale (POSS): Stop the medication infusion immediately. Stimulate the patient; raise the head of bed to seated position (if not contraindicated) and talk to patient (Jungquist et al., 2017a). Call the rapid response team (RRT) (Jungquist et al., 2017a). Notify the health care team. Administer oxygen and an opioid antagonist, such as naloxone, based on facility policy (ISMP, 2017). The dose of naloxone is titrated to effect—reversing the oversedation and respiratory depression, not reversing analgesia (Morton & Fontaine, 2018).
The patient's IV infusion line becomes infiltrated: Stop the PCA infusion and IV infusion. Remove the IV catheter and restart the IV line in another site. Once the site is established, resume the IV and PCA infusion. Provide site care to the infiltration site based on facility policy.
The patient's subcutaneous infusion site becomes infiltrated: Stop the PCA infusion. Remove the administration device. Obtain new administration equipment and restart the infusion at another site. Once the site is established, resume the PCA infusion. Provide site care to the infiltration site based on facility policy.

Special Considerations

General Considerations

A wide variety of PCA devices are available on the market. Check the manufacturer's instructions and facility policies before using any one device.
Provide individualized patient and caregiver education appropriate to the duration of therapy and care setting, treatment options, the purpose of PCA therapy, frequency of monitoring, expected outcomes, precautions, potential side effects, symptoms to report, and how dose will be adjusted (Gorski et al., 2021).
All patients should be assessed for level of risk of opioid-induced advancing sedation and respiratory depression; the plan of care and monitoring strategies should be driven by reassessment according to level of risk (Jungquist et al., 2020).
Continuous capnography and/or pulse oximetry has been suggested for use in all patients receiving PCA opioids for early detection of opioid-induced respiratory depression; continuous capnography should be used in all patients receiving supplemental oxygen (Fazio & Firestone, 2020; Khanna et al., 2020).
Adults and children who are cognitively and physically able to use the PCA equipment and are able to understand that pressing a button can result in pain relief are appropriate candidates for PCA therapy (DiGiusto et al., 2014; Gorski et al., 2021; Pasero & McCaffery, 2011).
Opioid analgesia via a continuous subcutaneous infusion is a safe, effective alternative when IV access is not available and oral analgesia is no longer possible. Candidates for subcutaneous infusion of analgesia are often patients requiring hospice and palliative care (Thomas & Barclay, 2015). Equipment consists of a small-gauge needle inserted subcutaneously, and an infusion pump and administration set that is clearly labeled subcutaneous infusion. This setup delivers the opioid in a small amount of fluid (Taylor et al., 2023). Nurses can initiate subcutaneous infusion therapy once competence has been validated. Assessment includes monitoring of vital signs, pain level, and the insertion site for leakage, bleeding, or other complications (Gorski et al., 2021).
PCA by proxy refers to activation of the PCA dosing button by anyone other than the patient (Grissinger, 2019). PCA by proxy is not recommended (Grissinger, 2019; ISMP, 2016). PCA by proxy can cause serious analgesic overdoses resulting in oversedation, respiratory depression, and death (Grissinger, 2019; ISMP, 2016). Institutions must verify that they have protocols in place to protect against unauthorized PCA delivery and it is recommended that clear warning labels stating, “WARNING: BUTTON TO BE PRESSED ONLY BY THE PATIENT” be attached to PCA pumps and tubing (Grissinger, 2019; ISMP, 2016).
Some facilities and health care agencies have developed clinical practice guidelines for authorized agent-controlled analgesia (AACA) for patients who are unable to independently utilize PCA (Cooney et al., 2013). In these cases, one family member or nurse is designated as the primary pain manager and only that person can press the PCA button for the patient (Benjenk et al., 2020). The patient and the caregiver must be assessed for appropriateness of use of AACA (Gorski et al., 2021). In the case of family members, the primary pain manager must be chosen carefully and taught to assess for pain and the adverse effect of the medication (Gorski et al., 2021). In addition, nursing staff must be vigilant in assessing the patient's need for and response to the medication, following the same assessment guidelines previously discussed. It is very important to follow facility guidelines to ensure safe administration (Benjenk et al., 2020; Cooney et al., 2013; D'Arcy, 2013). Box 10-2 outlines guidelines for safe implementation of AACA.
If using a device that provides continuous and bolus doses, the cumulative doses per hour should not exceed the total hourly dose prescribed by the health care provider.
Encourage the patient to practice coughing and deep breathing to promote ventilation and prevent pooling of secretions.
An opioid antagonist, such as naloxone, must be readily available in case the patient develops respiratory complications related to drug therapy. The dose of naloxone is titrated to effect—reversing the oversedation and respiratory depression, not reversing analgesia (Morton & Fontaine, 2018). If naloxone is administered, continue to closely assess the patient for oversedation and respiratory depression, as the half-life of naloxone (1.5 to 2 hours) is shorter than most opioids (Morton & Fontaine, 2018).

Infant and Child Considerations

PCA can be an effective method of pain control for a child. When determining the appropriateness of this therapy for a child, consider the child's chronologic age and developmental level, ability to understand (cognitive level), and motor skills (Pasero & McCaffery, 2011). It is essential to assess each child individually and consider their developmental level and psychosocial factors in determining appropriate PCA use. The child must have the necessary intellect, manual dexterity, and strength to operate the device (Kyle & Carman, 2021).

Community-Based Care Considerations

Be sure that the patient understands how to use the PCA device properly. Teach the patient how the device works, when to contact the health care provider, and signs and symptoms of adverse reactions and of drug tolerance.
Provide individualized patient and caregiver education appropriate to the duration of therapy and care setting, treatment options, the purpose of PCA therapy, frequency of monitoring, expected outcomes, precautions, potential side effects, symptoms to report, and how dose will be adjusted (Gorski et al., 2021).
Advise the patient, particularly those with preexisting cardiac disease and older adults, to change positions gradually to prevent orthostatic hypotension and syncope, which can result from use of an opioid analgesic (Chen & Ashburn, 2015).
Ensure that a reliable adult is available who can provide backup assistance should the patient have difficulty.
Collaborate to obtain a referral to a community-based health care provider team to continue teaching and provide assessment of the therapy.

EVIDENCE FOR PRACTICE

Authorized Agent-Controlled Analgesia

Patient-controlled analgesia is commonly used for pain management. However, many patients are unable to use patient-controlled analgesia due to physical or cognitive limitations (Benjenk et al., 2020). Is authorized agent-controlled analgesia, in which a nurse or designated care giver activates the analgesia device, an effective option for management of pain in these patients?

Related Evidence

Benjenk, I., Messing, J., Lenihan, M. J., Hernandez, M., Amdur, R., Sirajuddin, S., Davison, D., Schroeder, M. E., & Sarani, B. (2020). Authorized agent-controlled analgesia for pain management in critically ill adult patients. Critical Care Nurse, 40(3), 31-36. https://doi.org/10.4037/ccn2020323

The aim of this retrospective pilot study was to evaluate the efficacy of authorized agent-controlled analgesia in critically ill adult patients. Authorized agent-controlled analgesia (AACA) was initiated as a pain management intervention for 46 patients in a medical-surgical adult intensive care unit. Pain was measured using the Critical-Care Pain Observation Tool for the 24 hours before and after initiation of AACA, administered by nurses only. The mean pain score from before to after initiation decreased 69% (P ; .001). When the results were controlled for time, sedative administration, and opioid medication administration, the effect of AACA initiation on pain scores remained significant (P ; .001). The researchers concluded the use of AACA is associated with a reduction in pain in critically ill patients and suggested AACA as an effective means of providing analgesia in this patient population.

Relevance to Nursing Practice

Nurses have an important role in providing interventions to assist patients in controlling pain and improving comfort. Nurses have a responsibility to be informed and knowledgeable regarding all methods of analgesia and work to provide a plan of care that addresses individual patient needs.

EVIDENCE FOR PRACTICE

Assessment of Opioid-Induced Sedation

Opioids are used as part of the plan of care for pain management for patients in a variety of circumstances. There is a need to balance the achievement of adequate pain control while avoiding adverse effects, such as opioid-induced sedation and respiratory depression. Nurses must carefully monitor for oversedation and respiratory depression (Taylor et al., 2023). Assessment should include use of a sedation scale. There are several tools available to support these assessments. What is the evidence supporting use of these tools?

Related Evidence

Hall, K. R., & Stanley, A. Y. (2019). Literature review: Assessment of opioid-related sedation and the Pasero Opioid Sedation Scale. Journal of PeriAnesthesia Nursing, 34(1), 132-142. https://doi.org/10.1016/j.jopan.2017.12.009

The purpose of this literature review was to examine sedation scales and monitoring practices, specifically evaluating utilization of the Pasero Opioid Sedation Scale (POSS) in the clinical setting. Publications from January 2009 to June 2016 were searched using PubMed, the Cumulative Index to Nursing and Allied Health Literature, and Google Scholar Databases. Search terms included monitor, monitoring, opioid-induced, Pasero Opioid Sedation Scale, respiratory depression, and sedation. MeSH terms used were monitoring, physiologic; analgesics, opioid; respiratory insufficiency/complications/nursing, and prevention and control. The initial literature search identified 14 articles for review and analysis. Six articles were selected for review based on titles and abstracts: three descriptive survey-based design, two quasi-experimental design, and one evidence-based practice project. Of the six, two articles evaluated the safety and efficacy of the POSS in a clinical environment; one evidence-based practice project standardized the way nurses assess for and monitor opioid-induced sedation in general care areas; one investigated the validity and reliability of three sedation scales, including the POSS; and two studies evaluated monitoring practices related to sedation and respiratory depression. The researchers concluded there was a need for further research, as there was limited publication regarding implementation of a POSS in the PACU and other clinical settings. The authors also concluded additional research or evidence-based practice projects should be conducted to evaluate the tool's application to the general population, improved outcomes, and financial impact. The researchers suggested that, overall, the literature supports the goal of the POSS, citing the potential for fewer opioid-related adverse events and increased confidence among nursing staff.

Relevance to Nursing Practice

Nurses have an important role in monitoring for adverse effects related to health care interventions. Use of appropriate assessment tools can support critical assessments by nurses to support clinical reasoning and clinical judgment, contributing to delivery of safe, effective nursing care.

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Skill 10-4

EVIDENCE FOR PRACTICE

EVIDENCE FOR PRACTICE