(30689) PROT Pain PCA Adult Patient Controlled Analgesia
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1 Diagnosis Allergies Nursing Assess and Document PCA: 1. Assess and document pain rating, sedation level and respiratory rate every 2 hours; assess and document pain rating, sedation level and respiratory rate 30 minutes after any change in bolus dose. 2. Include continuous oximetry and/or spot checks. 3. Continuous suggested for elderly and debilitated patient and those with sleep apnea or cardiopulmonary issues. Nurse To Discontinue PCA Postoperatively By 12 PM on postop day [ ] if able to tolerate PO pain meds. Nurse to begin pain management order(s) as written after PCA is discontinued. Release order(s) if they are Signed and Held. Nurse To Discontinue PCA Specify Timeframe: Specify timeframe: [ ]. Nurse to begin pain management order(s) as written after PCA Discontinue PCA Medication Discontinue Medications Begin Bowel Management Program Insert Peripheral Line is discontinued. Release order(s) if they are Signed and Held. Nurse to contact physician to discontinue PCA for severe pruritis, nausea, or respiratory depression. For pruritis, nausea, or respiratory depressions when PCA is discontinued. 1. When patient tolerating clear liquids. 2. See Medication Section Bowel Management Program. 3. Begin if no bowel movement within 24 hours. 4. If impacted call physician for orders. Nurse to insert and maintain peripheral IV line. Nurse to Place IV Fluid Order for NaCl 0.9% IV Infusion 1000 ml Patient Should Not Receive Additional Parenteral Opiates While on PCA If no other maintenance IV fluid currently ordered. Infuse TKO to maintain line patency. Discontinue when PCA discontinued. Provider Initials Page 1 of 8
2 Respiratory Oxygen PRN to keep SaO2 greater than 90%. Consult to Respiratory Care (RCAT) Oximetry - Continuous Follow site specific protocol. Follow site specific protocol. Medications PCA (Single Select Section) Continuous infusion recommended ONLY if opioid TOLERANT this is defined as taking narcotics continually for at minimum the past week morphine PCA opioid NAIVE Final concentration = 1 mg/ml Loading Dose: [ ] mg (suggested 2 mg, range 2-5 mg) for 1 dose PCA bolus dose: [ ] mg (suggested range 1-2 mg) Lockout interval: [ ] min (suggested range 5-15 min) Four hour dose limit: [ ] mg (suggested max 30 mg) 50% (round down to nearest tenth of mg). [ ] mg. decrease PCA bolus dose by 50%. Provider Initials Page 2 of 8
3 HYDROmorphone (DILAUDID) PCA opioid NAIVE Final concentration = 1 mg/ml Loading Dose: [ ] mg (suggested 0.3 mg, range mg) for 1 dose. PCA bolus dose: [ ] mg (suggested range mg) Lockout interval: [ ] min (suggested range 5-15 min) Four hour dose limit: [ ] mg (Suggested max 6 mg). 0.1 mg [ ] mg decrease PCA bolus dose by 0.1 mg [ ] mg fentanyl (SUBLIMAZE) PCA opioid NAIVE Final concentration = 50 mcg/ml Loading Dose: [ ] mcg (Suggested 20 mcg) for 1 dose PCA bolus dose: [ ] mcg (Suggested range mcg) Lockout interval: [ ] min (Suggested range 5-10 min) Four hour dose limit: [ ] mcg (suggested max 400 mcg). 50% [ ] mcg decrease PCA bolus dose by 50%. morphine PCA opioid TOLERANT continuous infusion used *ONLY* if taking narcotics continually for Reason(s) for using TOLERANT PCA dosing: Provider Initials Page 3 of 8
4 the past week patient taking narcotics continually for the past week Other: Comments:[ ] Final concentration = 1 mg/ml. Loading Dose: [ ] mg (suggested 2 mg, range 2-5 mg) for 1 dose PCA bolus dose: [ ] mg (suggested range 1-2 mg) Lockout interval: [ ] min (suggested range 5-15 min) Continuous Infusion Rate: zero mg/hr,, suggested range mg/hr) Four hour dose limit: [ ] mg (suggested max 30 mg) 50% (round down to nearest tenth of mg). [ ] mg. turn off continuous infusion and decrease PCA bolus dose by 50%. HYDROmorphone (DILAUDID) PCA opioid TOLERANT continuous infusion used *ONLY* if taking narcotics continually for the past week Reason(s) for using TOLERANT PCA dosing: patient taking narcotics continually for the past week Provider Initials Page 4 of 8
5 Other: Comments:[ ] Final concentration = 1 mg/ml. Loading Dose: [ ] mg (suggested 0.3 mg, range mg) for 1 dose. PCA bolus dose: [ ] mg (suggested range mg) Lockout interval: [ ] min (suggested range 5-15 min) Continuous Infusion Rate: zero mg/hr, suggested range mg/hr) Four hour dose limit: [ ] mg (Suggested max 6 mg). 0.1 mg [ ] mg turn off continuous infusion and decrease PCA bolus dose by 0.1 mg [ ] mg fentanyl (SUBLIMAZE) PCA opioid TOLERANT continuous infusion used *ONLY* if taking narcotics continually for the past week Reason(s) for using TOLERANT PCA dosing: patient taking narcotics continually for the past week Other: Comments:[ ] Provider Initials Page 5 of 8
6 Final concentration = 50 mcg/ml Loading Dose: [ ] mcg (Suggested 20 mcg) for 1 dose PCA bolus dose: [ ] mcg (Suggested range mcg) Lockout interval: [ ] min (Suggested range 5-10 min) Continuous Infusion Rate: zero mg/hr (if opioid tolerant, suggested range mcg/hr) Four hour dose limit: [ ] mcg (suggested max 400 mcg). Opioid Antagonist naloxone (NARCAN) IV IV Antihistamines (Single Select Section) diphenhydramine (BENADRYL) IV diphenhydramine (BENADRYL) IV - for patients greater than 65 y.o. or less than 50 kg 50% [ ] mcg turn off continuous infusion and decrease PCA bolus dose by 50%. Q3 MIN PRN, Intravenous, Dose: 0.08 mg, PRN if respiratory rate is < 8/min or patient is difficult to arouse. Give 0.08 mg (0.2 ml) every 3 minutes and repeat up to 0.4 mg total (1 ml) or until patient is responsive to physical stimulation and is able to take deep breaths. Continue to observe, if no response within 3 minutes of administration of 0.4 mg total, repeat dose (0.4 mg as administered previously) and notify physician STAT. Q6H PRN, Intravenous, Dose: 25 mg, PRN for itching. Q6H PRN, Intravenous, Dose: 12.5 mg, PRN for itching. Oral Antihistamines (Single Select Section) diphenhydramine (BENADRYL) PO diphenhydramine (BENADRYL) PO - for patients greater than 65 y.o. or less than 50 kg IV Antiemetics (Select All 3) Q6H PRN, Oral, Dose: 25 mg, PRN for itching. Q6H PRN, Oral, Dose: 12.5 mg, PRN for itching. Provider Initials Page 6 of 8
7 ondansetron (ZOFRAN) IV droperidol (INAPSINE) IV prochlorperazine (COMPAZINE) IV Oral/Rectal Antiemetics prochlorperazine (COMPAZINE) PO prochlorperazine (COMPAZINE) PR Q6H PRN, Intravenous, Dose: 4 mg, PRN for nausea/vomiting. This medication is 1st choice for control of nausea/vomiting. If ineffective, causing adverse effects or patient preference, consider droperidol. Q6H PRN, Intravenous, Dose mg. PRN for nausea/vomiting if ondansetron ineffective. Maximum dose 2.5 mg in 24 hours. If ineffective, causing adverse effects or patient preference, consider prochlorperazine. Q6H PRN, Intravenous, Dose: 10 mg, PRN for nausea/vomiting. This medication is 3rd choice for control of nausea/vomiting. If ineffective, causing adverse effects or patient preference, then contact physician. Q6H PRN, Oral, Dose: 10 mg, PRN for nausea/vomiting. Q12H PRN, Rectal, Dose: 25 mg, PRN for nausea/vomiting. Bowel Management (Select All 3) docusate-senna ( mg) (SENOKOT-S) PO milk of magnesia PO milk of magnesia PO bisacodyl (DULCOLAX) PR BID, Oral, Dose: 1-4 tablets, Begin when tolerating clear liquids. Initial dose: 2 tablets for 2 doses. If no results, increase to 3 tablets for 2 doses. If no results, increase to 4 tablets. If greater than 2 bowel movements in 24 hours at any point, reduce to 1 tablet. BEDTIME, Oral, Dose: 30 ml. Give POD#1 for one dose if no bowel movement within 24 hours of initiation of SENOKOT-S. BEDTIME PRN, Oral, Dose: ml, PRN constipation. Starting POD#2. ONE TIME PRN, Rectal, Dose: 10 mg, PRN constipation. Give if no bowel movement by the evening after administration of milk of magnesia and impaction is ruled out. Additional Orders Provider Initials Page 7 of 8
8 Provider Signature Date Time Provider Initials Page 8 of 8
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