Week 4 Lecture Notes: PCAs, Stomas, Drains, Tubes, and IDCs

PCAs - The Basics

  • Patient-controlled analgesia (PCA) allows patients to self-administer opioid medications using a programmed pump.

  • The pump delivers medication via continuous infusion, on-demand doses, or a combination.

  • Nurses must monitor for respiratory depression. —> Opiods can affect the brain’s respiratory centres

  • PCA Medication Order Principles:

    • Loading dose: Initial dose at PCA start. Think: What is initially loaded at the PCA start

    • Demand dose: Dose upon button activation. Think: Dose on demand; when the patient presses the button

    • Lockout interval: Time before another dose can be administered.

    • Basal infusion: Continuous medication administration.

    • Lockout maximum: Max dose in a time period.

    • Breakthrough bolus dose: Given by nurse for breakthrough pain.

  • PCA solutions require a dedicated line or a side arm with a non-return valve.

  • Maintain IV fluids (minimum 5mL/hr) to prevent IV occlusion.

  • Treatment for opioid overdose: naloxone (Narcan).

  • Prescriber must specify medication, concentration, demand dose, lockout interval, and lockout maximum.

  • Two RNs should verify the PCA order during initiation.

  • Common Medications: morphine, hydromorphone, fentanyl, and oxycodone, alongside naloxone and anti-emetics.

  • Adverse Effects: decreased level of consciousness, respiratory distress, hypotension, constipation, urinary retention, nausea, vomiting and pruritus

  • Patient Education: Only the patient should initiate the demand dose when alert.

  • Nursing Assessment and Care:

    • Continuous pulse oximetry and frequent vital signs.

    • Frequent pain assessment.

    • Monitoring demands and doses received.

    • Two RNs to check PCA settings at the start of each shift.

    • Two RNs to document remaining medication upon PCA discontinuation.

Stomas and Assessment

  • Psychological preparation and education are crucial for stoma patients.

  • Stoma placement considerations: over the rectus muscle, on a flat surface, visible to the patient, away from skin creases and clothing lines.

  • Reasons for Ostomy: GI disease, cancer, congenital defects.

  • Ostomy Surgery: creates an opening in the abdomen for waste.

  • Types of Ostomies:

    • Colostomy: large bowel diversion. —> Think: as in it diverts stool away from the bowel

      • Descending: (L) upper abdomen

      • Ascending: (R) area of abdomen

      • Transverse: Mid-abdomen

      • Sigmoid: (L) lower abdomen

    • Ileostomy: small intestine diversion, liquid output, (R) lower quadrant

    • Jejunostomy: proximal small intestine, watery and corrosive output

    • Mucous fistula: distal bowel end brought to the abdomen

    • Double barrel ostomy: both ends of bowel brought to the surface, one for waste, the other for mucous

  • Immediate Post-operative Period Ongoing Stoma Observations includes Visual check of the stoma for presence of a bridge —> support for the stoma in the initial post-operative period.

  • Stoma Observations:

    • Colour: red/dark pink (healthy), pale pink (low haemoglobin), dark red/purplish (bruising), grey to black (ischemia/necrosis).

    • Appearance: Healthy - red/pink and moist. Injurious - lacerations may occur due to handling

    • Shape – round, oval, irregular

    • Protrusion: Normal - above skin line 0.5 – 1 cm approximately/protruding, Flush - at the level of the skin, Prolapsed - protrusion of stoma more than 2-3cm

    • Mucocutaneous Junction —> Where the skin and mucous membranes meet: Intact– Sutures intact all the way around. Separated – an area of stitches has become separated

    • Peristomal Skin —> Skin around the stoma : Colour - healthy (should be the same as “normal” skin), erythema, bruising Integrity - intact, macerated, eroded, rash, ulcer, incision Turgor - soft, elastic, flaccid, firm

  • Postoperative Complications:

    • Bleeding:

      • Excessive bleeding is not normal and should be reported to the medical team.

    • Prolapsed stoma: Document approximate length of protrusion and observe for signs of reduced perfusion. Think: the further it is from the body the less blood it will receive

    • Retracted stoma: creates issues around wound and peri-stomal skin integrity

    • Ischemia/Necrosis: requires urgent medical attention

    • Mucocutaneous seperation: detachment of the stoma's mucosal edge from the skin

    • Peristomal skin breakdown: skin inflammation, injury, or damage around an abdominal stoma

    • Wound breakdown: occurs when the wound edges separate, potentially causing leaks and discomfort

  • Patient Education:

    • Skin care, diet, odour control, stoma care, changing and emptying appliances, identifying complications.

Drains, Tubes and IDCs

  • Patients undergoing hemicolectomy may have drains, NGTs, and IDCs.

  • Drain Tube: remove pus, blood or other fluid, preventing it from accumulating in the body.

  • Types of Drains:

    • Jackson-Pratt: A soft pliable tube with multiple perforations and a bulb that can recreate low negative pressure vacuum

    • Redivac: A high negative pressure drain used for larger draining amounts of fluid.

    • Pigtail: Small lumen with a coil in the shape of a pigtail, used for draining a single cavity, passive drains, easily blocked (discuss with treating/surgical team if safe to flush).

    • Penrose: Flat ribbon-like drain, gauze or a drainage bag is applied to external end to absorb drainage.

    • Mini-vacuum Drain: A low suction system ideal for minor operations requiring less fluid drainage.

    • Bellovac: A closed wound drainage system that is designed to be activated and suctioned on low pressure.

  • Assessment:

    • Assess drain insertion site for signs of fluid or air leakage, redness or irritation to the skin.

    • Assess if the drain is maintaining suction.

    • Monitor for infection

  • Removal:

    • Removal of a drain tube is a sterile procedure using ANTT principles.

  • Nasogastric Tubes (NGT):

    • Used for short-term tube feeding, medication administration, and gastric suctioning.

    • Two types: single lumen (feeding) and double lumen (suctioning).

  • Insertion of a NGT: threading a flexible tube through one nostril, down the esophagus, and into the stomach, typically for feeding or medication delivery. Think: Nose → Nasopharynx → Oropharynx → Esophagus → Stomach

  • Assessments and Interventions:

    • Observe for signs of misplacement post-insertion, such as circumoral cyanosis, coughing, choking, dyspnea, decreased oxygen saturation level, or vomiting.

    • Do not administer fluids or medications via the NG tube until accurate placement has been verified with an X-ray.

  • Routine Nursing Care of Clients with NG Tubes:

    • Keep the head of the bed 30 degrees or higher.

    • Prevent migration and/or dislodgement of the tube.

    • Maintain and promote comfort.

    • Perform oral care.

    • Monitor input/output, electrolyte balances, and weight trend.

    • Monitor for potential complications.

  • In-dwelling Catheters (IDC):

    • Used to drain the bladder, measure urine output, relieve retention or incontinence.

  • IDC Nursing Assessments:

    • Measure urine output 1 – 4 hourly.

    • The IDC insertion site and securement should be assessed at least once a shift.

    • IDC drainage bags should be emptied once a shift at a minimum.

    • Position drainage bag to prevent backflow of urine or contact with the floor.