7/25/2014 RE: PCA Monitoring - Davis, Aurora

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RE: PCA Monitoring
Rockstars,
In response to a request from one of our permanent charge nurses, I've developed a tip sheet regarding
PCA use and documentation to try to answer some FAQs. The tip sheet is attached and will be going on
either SharePoint or the share drive for easy access. As always, let me know if you have any questions.
Thanks,
Aurora
Aurora Davis, RN, BA, BSN, OCN
Relief Charge Nurse
Oncology and Bone Marrow Transplant Unit
University of Colorado Hospital
Aurora.Davis@uchealth.org
From: Davis, Aurora
Sent: Wednesday, February 19, 2014 11:12 AM
To: UCH-AIP 11th Onc RN
Subject: PCA Monitoring

Wonderful nurses,

I'm really distressed to report that we had an incident on Sunday on the OMG unit where it was discovered
that a patient who had been on a PCA for over 48H had NEVER had a sedation assessment charted. This
should never happen! Part of the required nursing monitoring for PCAs is that the patient's respirations
and sedation will be charted per hospital policy.

I know we have a lot of relatively new staff and new grad nurses on the units right now, so I want to give
everyone a quick recap of required monitoring for PCAs.
Respiration rate and sedation level must be checked and charted Q1H for the first 12H after initiating
the PCA, Q2H for the next 12H, and Q4H any time after that. In addition, the respiration rate and
sedation must be checked Q30M x2 whenever the patient is given a PCA bolus dose or the settings
Davis, Aurora
Tue 4/1/2014 2:14 PM
To:UCH-AIP 11th Onc RN <UCH-AIP_11th_Onc_RN@uchealth.org>;
1 attachment
PCA Tip Sheet v2.pdf;
7/25/2014 RE: PCA Monitoring - Davis, Aurora
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are increased; after those two Q30M checks, you can return to the patient's current RR/sedation
check frequency.
Also, sedation needs to be documented in the Sedation section under the Vital Signs tab (can also be
found under the Pain Management tab). Look for the line labeled Moline-Roberts Sedation Scale. If you
have questions about the scale, there's a very detailed cheat sheet on your EPIC dashboard, as well as
some instructions for using it.
Please, come and talk to me if you have any questions about this. Monitoring is so important to protect our
patients from oversedation while, at the same time, managing their pain.
Thank you, rockstars!
Aurora

Aurora Davis, RN, BA, BSN, OCN
Relief Charge Nurse
Oncology and Bone Marrow Transplant Unit
University of Colorado Hospital
Aurora.Davis@uchealth.org