morphine 30 mg/ 30 ml (1 mg/ml) Opioid of choice
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1 PATIENT CONTROLLED ANALGESIA (PCA) PLAN Allergies: Medication Selection: morphine 30 mg/ 30 ml (1 mg/ml) Opioid of choice HYDROmorphone (Dilaudid ) 6 mg/ 30 ml (0.2 mg/ml) fentanyl 300 mcg/ 30 ml (10 mcg/ml) meperidine (DEMEROL) 300 mg/ 30 ml (10 mg/ml) See dosing note #4 Loading dose: mg mg mcg mg PCA Dose: mg mg mcg mg Lockout Interval: minutes minutes minutes minutes 4 hour limit: mg mg mcg mg *** CAUTION *** CAUTION *** CAUTION *** CAUTION *** CAUTION *** CAUTION *** CAUTION *** CONTINUOUS RATE SHOULD BE RESERVED FOR OPIOID TOLERANT PATIENTS WHO REQUIRE HIGH DOSE THERAPY Continuous Rate: mg/hr mg/hr mcg/hr mg/hr DOSING NOTES: 1 Initial doses are for opioid naive patients. Chronic pain patients may require higher doses. 2 Decrease initial starting dose by 25-30% in patients > 65 yrs, or patients with renal, hepatic, or pulmonary impairment. 3 Hydromorphone and fentanyl are recommended for patients with renal impairment or those intolerant of morphine. 4 Avoid meperidine use in patients > 65 yrs, renal impairment, seizure disorders, MAO inhibitors, or duration > 72 hrs. Reserve meperidine use for patients intolerant to all other opioids. Page 1 of 5 Patient Controlled Analgesia (PCA) Plan 05/07//2012 (#827 R-5)
2 GUIDELINES PATIENT CONTROLLED ANALGESIA (PCA) PLAN DRUG PARAMETERS INITIAL SETTING ADULT morphine HYDROmorphone fentanyl meperidine ADULT ( > 65 yrs) Loading Dose 2 mg 1-3 mg mg PCA Dose 1 mg mg mg 4 Hour Limit 20 mg mg mg Continuous Rate *CAUTION* 1 mg/hr mg/hr mg/hr Loading Dose 0.4 mg mg mg PCA Dose 0.2 mg mg mg 4 Hour Limit 4 mg 4 6 mg mg Continuous Rate *CAUTION* 0.2 mg/hr mg/hr mg/hr Loading Dose 25 mcg mcg 7 20 mcg PCA Dose 10 mcg 5 20 mcg 4 15 mcg 4 Hour Limit 300 mcg mcg mcg Continuous Rate *CAUTION* 5 mcg/hr 5 10 mcg/hr 4 8 mcg/hr Loading Dose 25 mg mg mg PCA Dose 10 mg 5-20 mg 4-15 mg Lockout Interval 10 min 5-10 min 10 min 4 Hour Limit 150 mg mg mg Continuous Rate *CAUTION* 10 mg/hr mg/hr 7-15 mg/hr MONITORING: Respiratory rate/sedation level/pain assessment every 15 mins X 2, every 1 hrs X 4 hr, then if stable every 4hrs Repeat monitoring following bolus doses or changes in PCA dosages. Notify provider for inadequate pain relief Place and monitor pulse oximetry Notify physician if SpO 2 less than 92%. Notify provider if Alertness Score is 3 or greater: S = Sleep, easy to arouse 1 = Awake and alert 2 = Slightly drowsy, easily arousable 3 = Frequently drowsy, arousable, drifts off to sleep during conversation 4 = Somnolent, minimal or no response to physical stimulation IV FLUIDS: If no IV fluid is currently infusing, start 0.9% sodium chloride at KVO for duration of PCA Other: Page 2 of 5 Patient Controlled Analgesia (PCA) Plan 05/07//2012 (#827 R-5)
3 PRN MEDICATIONS: Refer also to Admission Medication Reconciliation Form and Discomfort Orders HEADACHE: Acetaminophen (Tylenol ) 650 mg PO or rectal q6h PRN Other: ACUTE MANAGEMENT OF RESPIRATORY DEPRESSION: If respiratory rate is less than 10/min or patient is unresponsive Stop PCA pump Dilute naloxone (Narcan ) 0.4 mg (1ml) in 9 ml NS and administer 0.1 mg (2.5 ml) by IVP every 2-3 minutes until respiratory rate is greater than 10 Notify physician Page 3 of 5 Patient Controlled Analgesia (PCA) Plan 05/07//2012 (#827 R-5)
4 PATIENT DISCOMFORT MEDICATION PLAN Indicate desired medications by checking appropriate box. If more than one box is checked for an indication, then use the ordered medications in the descending order. PAIN MANAGEMENT: (TARGET MAXIMUM OF 3000 MG OF ACETAMINOPHEN PER 24 HOURS FROM ALL SOURCES) (DO NOT EXCEED 4000MG OF ACETAMINOPHEN PER 24 HOURS) MILD PAIN (Pain Scale 1-3): Acetaminophen (Tylenol) mg PO every 4 hours PRN mild pain (Do not exceed 4,000 mg in 24 hours), if NPO use: Acetaminophen (Tylenol) 650 mg suppository PR every 4 hours PRN mild pain (Do not exceed 4,000 mg in 24 hours), if acetaminophen is ineffective/contraindicated use: Ibuprofen (Motrin) 400 mg PO every 6 hours PRN mild pain (Do not exceed 3,200 mg in 24 hours) MODERATE PAIN (Pain Scale 4-7): Hydrocodone/acetaminophen (Lortab) 5/500 mg 1 2 tabs PO every 4 hours PRN moderate pain (Do not exceed 4 grams of acetaminophen in 24 hours), if ineffective/contraindicated or NPO use: Ketorolac (Toradol) mg IV every 6 hours PRN moderate pain x 48 hours (May give IM if no IV access) Other SEVERE PAIN (Pain Scale 8-10): Morphine 2 4 mg slow IV push every 4 hours PRN severe pain, if ineffective/contraindicated use: Hydromorphone (Dilaudid) 1 mg slow IV push every 4 hours PRN severe pain PCA Initiate UMC Adult Patient Controlled Analgesia PCA Orders NAUSEA/VOMITING: Promethazine (Phenergan) 25 mg PO every 4 hours PRN nausea/vomiting, if ineffective/contraindicated or NPO use: Ondansetron (Zofran) 4 mg IV every 8 hours PRN nausea/vomiting BOWEL MANAGEMENT: Docusate (Colace) 100 mg PO at bedtime PRN for constipation, if contraindicated or ineffective after 12 hours use: Bisacodyl (Dulcolax) 10 mg suppository PR daily PRN constipation, if contraindicated or ineffective after 6 hours use: Sodium phosphate enema (Fleet enema) PR daily PRN constipation (Do not use in renal patients) INDIGESTION/GAS: DIARRHEA: Aluminum hydroxide/magnesium hydroxide (Maalox) 30 ml PO every 4 hours PRN indigestion Simethicone (Mylicon) mg PO every 4 hours PRN gas/bloating Loperamide (Imodium) 4 mg PO initially then 2 mg PO with each loose stool (Max 16 mg hours) Page 4 of 5 Patient Controlled Analgesia (PCA) Plan 05/07//2012 (#827 R-5)
5 Page 5 of 5 Patient Controlled Analgesia (PCA) Plan 05/07//2012 (#827 R-5) Indicate desired medications by checking appropriate box. If more than one box is checked for an indication, then use the ordered medications in the descending order. ANXIETY: Alprazolam (Xanax) 0.25 mg PO three times a day PRN anxiety, if ineffective/contraindicated or NPO use: Lorazepam (Ativan) mg IV every 6 hours PRN anxiety SLEEPLESSNESS: Zolpidem (Ambien) 5 mg PO at bedtime PRN sleeplessness, may repeat x 1 in one hour if ineffective ALLERGIC REACTIONS: Diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching, if ineffective or NPO use: Diphenhydramine (Benadryl) 25 mg IV every 4 hours PRN itching COUGH / SORE THROAT: Phenol-menthol (Cepastat) 1 lozenge PO PRN sore throat (Do not exceed 6 lozenges in 24 hours) Guaifenesin/dextromethorphan (Robitussin DM) 10 ml PO every 4 hours PRN cough TEMPERATURE: Acetaminophen (Tylenol) mg PO every 4 hours PRN fever (Do not exceed 4,000 mg in 24 hours), if ineffective/contraindicated use: Ibuprofen (Motrin) mg PO every 4 hours PRN fever (Do not exceed 3,200 mg in 24 hours) HEMORRHOIDS: MUCOSITIS: Witch hazel/glycerin (Tucks) pads at bedside wipe affected area as PRN, if ineffective use: Mineral oil/petrolatum/phenylephrine (Preparation H) ointment apply to affected area every 6 hours PRN. If ineffective/contraindicated use: Pramoxine/hydrocortisone (Proctofoam HC) at bedside apply to affected area every 8 hours PRN Dexamethasone/diphenhydramine/nystatin/NS (Fred s Brew) 15 ml swish and spit every 2 hours while awake PRN mucositis. If ineffective/contraindicated use: Viscous lidocaine (Xylocaine) 15 ml swish and spit every 4 hours PRN mucositis BLADDER SCAN: Bladder scan as needed for patients complaining of urinary discomfort and/or bladder distention present OR 6 hours post- Foley removal and patient has not voided. If bladder scan volume is >250 ml please notify the physician. OTHER:
1. Attending Physician: Dr Syn Pager: Cell: Co-Morbidities:
BARIATRIC SURGERY IMMEDIATE POST-OP PLAN (Includes Post Op Day 1) Denotes order requirement Antibiotic administered in the OR at: 1. Attending Physician: Dr Syn Pager: 740-6545 Cell: 438-9415 2. To remain
A UMC Health System Performance Improvement Initiative for use in all units where cardiac/surgical patients are admitted.
A UMC Health System Performance Improvement Initiative for use in all units where cardiac/surgical patients are admitted Denotes guideline requirement Attending Physician: Resident/Fellow: Allergies_ Diagnosis:
A UMC Health System Performance Improvement Initiative for use in all units where patients with are admitted for Surgical Care Improvement Project.
ENDOLUMINAL AAA POST-OP PLAN A UMC Health System Performance Improvement Initiative for use in all units where patients with are admitted for Surgical Care Improvement Project. *Denotes guideline requirement
Procedure: Laser Transurethral Resection of Prostate or Transurethral Resection of Prostate
Laser Transurethral Resection Of Prostate Or Transurethral Resection Of Prostate Post-Operative Plan Patient Label Here A UMC Health System Performance Improvement Initiative for use in all units where
EPIDURAL / INTRATHECAL POST-OP PLAN
EPIDURAL / INTRATHECAL POST-OP PLAN Diagnosis Weight PHYSICIAN S Allergies Patient Care Vital Signs Per Unit Standards, PLUS check and record RR q1h x 12, then q2h x 6, until 24h following narcotic administration.
1. Attending Physician: Resident/Fellow: 2. Admit: MEDICAL/SURGICAL ICU Other: Designation: In Patient Out Patient. 5.
UROLOGY POST OPERATIVE PLAN Patient Label Here A UMC Health System Performance Improvement Initiative for use in all units where surgical patients receive care in support of Surgical Care Improvement Program
1. Attending Physician: Resident/Fellow: 2. Consult
COLON POST OP PLAN A UMC Health System Performance Improvement Initiative for use in all units where surgical patients receive care in support of Surgical Care Improvement Program (SCIP). * Denotes guideline
Patient Label Here CAROTID POST OP PLAN. Antibiotic administered in the OR at: Physician Signature Date/Time
CAROTID POST OP PLAN A UMC Health System Performance Improvement Initiative for use in all units where patients with carotid surgery are admitted in support of the Surgical Care Improvement Program (SCIP).
ENT THYROIDECTOMY/PARATHYROIDECTOMY POST OP PLAN - Phase: Begin Immediately/PACU
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ENT THYROIDECTOMY/PARATHYROIDECTOMY POST OP ADMIT PLAN - Phase: Begin Immediately/PACU
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GENERAL SURGERY POST-OP PLAN
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LYSIS OF ADHESIONS POST-OP PLAN - Phase: PACU Phase
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Patient Label Here. ORTHOPEDIC POST-OPERATIVE ADMIT PLAN (Includes Post Op Days 1-2) Antibiotic administered in the OR at:
ORTHOPEDIC POST-OPERATIVE ADMIT PLAN (Includes Post Op Days 1-2) A UMC Health System Performance Improvement Initiative for use in all units where surgical patients receive care in support of Surgical
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GENERAL SURGERY PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom Privileges
THROMBOLYTIC THERAPY FOR PERIPHERAL OCCLUSION
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UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
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(30689) PROT Pain PCA Adult Patient Controlled Analgesia
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ADMIT GENERAL MEDICINE PLAN - Phase: Begin Immediately
- Phase: Begin Immediately Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Patient Status Patient Condition Acuity Level Floor Status Acuity Level Critical Acuity Level Intermediate Continuous Telemetry
GENERAL MEDICINE PLAN
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OB/GYN CESAREAN SECTION POST-OP PLAN - Phase: General Orders
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PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase: Pediatric Spine Surgery General Orders
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PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Patient Activity Bedrest Maintain Surgical Drain Maintain JP Drain, Measure Output q12h, and PRN Convert IV to INT when tolerating
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GENERAL UROLOGY PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Strict Intake and Output Per Unit Standards q4h q12h Patient Activity Assist as Needed Up in Chair,
TRANSCATHETER AORTIC VALVE REPLACEMENT POST- OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards, q15min x 4, q30min x 2, then q1h x 4 until sheath discontinued. Per Unit Standards Perform Neurovascular
OPEN AAA/MAJOR ABDOMINAL POST-OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Maintain Gastric Tube Maintain Nasogastric - NG, Low Intermittent Suction Maintain Nasogastric - NG, Low Constant
UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
GI BLEED PLAN UMC Health System Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Notify Provider of VS Parameters Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist
TRANSCATHETER AORTIC VALVE REPLACEMENT POST- OP ADMIT PLAN - Phase: Begin Immediately/PACU Phase
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ISCHEMIC STROKE/TIA PLAN
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ADMIT CHEST PAIN PLAN - Phase: Begin Immediately
- Phase: Begin Immediately PHYSICIAN S Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: CICU, Pt Status: Observation (LOS < 2 midnights) Requested Location: 5E / IMCU,
STROKE NEUROINTERVENTION PLAN - Phase:.
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IV Acetaminophen Pain Study for Neurosurgery Post Op Non ICU Admit Plan Begin Immediately/PACU
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