PCA, Glasgow Coma Scale,
Canadian Neurological Stroke
Scale
Patient controlled Analgesia





Breaks the pain cycle
Gives the control to the
patient (often using less
narcotic)
Avoids peaks and
valleys
Decreases chance of
errors
Decreases nursing
workload
Mechanics of the various systems of
PCA
RN programs pump according to Dr’s
orders in dose increments( 2 nurse check)
 Minimum interval between doses (lock
out period)
 Client initiates dose by pressing hand
held button
 IV is tkvo or at a regular rate
 Usually morphine/ fentanyl/ demerol

Who is a candidate for PCA?
Must need parenteral meds
 Must have a willingness to operate pump
 Mentally alert and competent
 Able to follow instructions

who Isn’t
Patients with chronic pulmonary disease
(predisposition to respiratory depression)
 History of drug abuse
 Major psychiatric disorders
 Children (some)
 Some elderly etc

roles

RPN Role:
 Assessment
 Documentation (pca
assessment and
sedation score)
 Reporting tolerance
& changes, + & -





RN role:
Program pump
Ongoing assessment
Documentation
Maintenance of
medication syringes
in the pump
Assessment
Baseline vital signs
 Ongoing comparison to baseline
 Allergies
 Assess pain and sedation level
 Volume delivered and attempts made

Teaching
Usually done pre-op so the patient
understands how it works
 Should provide both written and verbal
instructions (how to notify staff if
inadequate control, change in pain
intensity, machine malfunction, alarms

Pain Team
Usually comprised of and RN/Nurse
Practitioner with Pain Management
training
 MD- usually an Anesthetist

Neuro assessments -CVA
To assess state of neurological impairment &
pick up subtle changes
1. Pupillary Response :
2. Mentation:
3. Motor Function: Expressive or Receptive
4. Vital Signs
*refer to handouts- Canadian Neurological Stroke
Scale and Neurological Observation Record
Pupillary response
Size
 Shape
 Reaction to light
 Ability to move together
 Equal bilaterally?

Mentation
LOC
alert/drowsy
 Orientation
oriented/disoriented
 Speech
normal
receptive deficit- unable to understand
written or spoken words
expressive deficit – understands but
unable to write or speak effectively

Motor Function-Expressive
Face
 Arm
 Arm
 Leg
 Leg

-smile
-proximal
-distal
-proximal
-distal
Motor Function-Receptive
Face mimic grin or watch expression
with pressure to sternum
 Arms place arms outstretched @ 90
 Legs place thighs toward body

Vital Signs
Assess resp. watch for cheyne-stokes,
rate and rhythm
 Watch for widening pulse
pressure(difference between systolic and
diastolic pressure)
 Can signifiy increased Intrcranial
Pressure or ICP

Glasgow Coma Scale
Assess depth and duration of coma &
impaired consciousness
 Used for acute brain injury D/T:
-traumatic injury
-vascular injury
-infections
-metabolic disorders(hypoglycemia, renal failure,

ketoacidosis, hepatic failure)
Glasgow coma scale
Head Injury Classification (GCS)
COMA: No eye opening, No ability to
follow commands,No word verbalizations
 Death
less than 3
 Severe H I
3 to 8
 Moderate H I
9 to 12
 Mild H I
13 to 15
 Normal
15
Learning activities

Complete Neurological Stroke Scale on
your partner and switch

Complete Glasgow Coma Scale on your
partner and switch