PCA morphine is a common method used to achieve pain control in the hospital setting. PCA stands for patient controlled analgesia. This therapy usually involves intravenous opiate therapy. Intravenous opiate management should be taken seriously by hospital nurses and doctors as too much medication can result in a life threatening iatrogenic drug overdose. In most situations, patients will respond rapidly to Narcan, the antidote in opiate overdoses. This complication happens everyday in the hospital, even during optimal monitoring conditions. Many foreseeable and unforeseeable variables are responsible. In fact, IV opiate management is even considered high risk drug management for physicians trying to calculate their medical decision making on their daily hospital E/M codes.
Many hospitals have standard protocols for initiating PCA morphine or other intravenous opiates. In addition to morphine, intravenous hydromorphone (Dilaudid) and fentanyl are other common medications used to achieve pain control. All intravenous opiates that should be prescribed with caution. How does a physician choose one medication over another? Considerations include patient preference and experience, physician preference and experience, patient drug allergy profiles, hospital wholesale costs and availability, trial and error for patient response and side effect profiles are just some of the most common reasons to choose one intravenous PCA opiate over the other.
Why is PCA morphine dangerous? Too much medication can cause patients to stop breathing. Opiates, often inappropriately referred to as narcotics by doctors and nurses, suppress the central nervous system's respiratory drive and increases the risk of life threatening apnea. This is the cause of death in a heroin overdose. This is the cause of death in the epidemic of prescription opiate drug overdoses heard about on the news. Many PCA morphine order sets require continuous oxygen saturation monitoring and frequent documentation of respiratory rate as safety mechanisms. This is to protect the patient from experiencing prolonged hypoxemia as a result of too much sedation when no family is available at the bedside.
How does the PCA morphine protocol work? The intravenous medication is placed inside a special pump secured to an IV pole. The pump is set to deliver medication through a patient's IV at the rate based on the physician's order. Doctors may or may not prescribe a continuous infusion dose (basal rate) in addition to an as needed (prn) dose for patient comfort. Patients are given a button to push for on demand delivery of medication for management of their severe pain. This button tells the pain pump to deliver intravenous morphine at a dose determined by the doctor's orders.
On the PCA morphine protocol orders, the doctor will write for a prn bolus dose with a lockout period. In other words, if the doctor only allows 1 mg of morphine every 8 minutes, then the patient will receive a maximum of 1 mg every eight minutes, if they push their pain button at least once every 8 minutes. If the patient pushed their button 100 times in that eight minutes the pain pump settings will only allow one 1 mg bolus dose to be delivered every eight minutes. This is the lockout period.
The customary lockout period for most of the IV opiates is to allow one dose of pain medication every 5-15 minutes, the exact time period of which is determined by the physician's order. This is a built in safety method to prevent a patient from overdosing on the medication. If patients become too sleepy to push the pain button, they will stop pushing it. This is also why families need to understand when it is safe to push the patient's PCA button and when it is not. Please consult with your nurse before you push your loved one's pain button. You may be killing them by doing so.
Hospitals are invested in optimizing severe pain control management because patient satisfaction scores depend on it. If patients believe their pain is not being adequately addressed, hospitals will get dinged on their HCAHPS surveys and they risk losing millions of Medicare dollars. PCA morphine is one way to give patients control of their severe pain management in the hospital and to ensure great survey scores on the back end.
How does the doctor determine the correct dosage of the basal and as needed bolus morphine? That's the wild, wild west of PCA management. Some hospitals have simplified the process, as these medical ecards explain. You can't get any more satisfied than less than one call light per shift, and by satisfied I mean nurses AND patients. Consider implementing these dosing protocolsfor your PCA morphine orders in your hospital today and experience great patient and nursing satisfaction scores in an instant!
"I have trained my doctors to write for PCA morphine with a basal rate of less than one call light request per shift. Hooray!"
"Morphine was named after Morpheus, the god of dreams. If you ask me for morphine, I will get you a pillow. For sleep. Just so you know."
"If Dilaudid was a Hamburder. Dilaudid is 7-10 times more potent than Morphine!"
"I haven't charted a true respiratory rate since nursing school. Just so you know."
"Admit for pain control patients usually go home the next day with orders to go to the ER if having pain. Just so you know."
"In an effort to improve patient perception scores, all nurses at my hospital are now trained to prepare freebase Oxy when 'nothing is working.'"
"If you tell me nothing is really helping your patient, I'm going to order nothing to help you. Just so you know..."
I see here that you quit smoking the day you got admitted to the hospital. That's too bad. I was going to write you a script for medical marijuana to help with your pain."
This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.
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