Neuraxial opioid Single dose Observation Chart - adult
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1 Neuraxial opioid Single dose Observation Chart - adult A presentation prepared by the Pain Interest Group Nursing Issues in association with the Agency of Clinical Innovation Pain Management Network Please direct comments to: Emily Edmonds Coordinator State Pain Forms Pain Interest Group Nursing Issues CNC Acute Pain Service Blacktown Hospital Phone: emily.edmonds@swahs.health.nsw.gov.au OR Jenni Johnson Manager Pain Management Network Agency for Clinical Innovation (ACI) Phone: jenni.johnsons@aci.health.nsw.gov.au December 2012
2 Neuraxial opioid single dose Observation chart - adult The neuraxial opioid single dose observation chart for adult patients has been developed by a team of experts in the field of acute pain including clinical nurse consultants, anaesthetists and pharmacy representatives. Standardisation of this chart promotes best practice in pain assessment and management of adverse effects in those patients who have received an opioid via the neuraxial route.
3 Aim of this presentation: This presentation aims to explain how to use the chart to record the administration of an opioid via the neuraxial route how to complete the clinical observations guidelines on the management of patients who have received an opioid via the neuraxial route including the management of adverse effects
4 Neuraxial Opioid Single Dose Observation Chart - adult Page 1: - Neuraxial opioid administration information - Naloxone prescription - Management guidelines Inside pages: - Observation pages for maximum 2 days Back page: - Clinical review and Rapid Response Criteria - Management of adverse effects
5 Patient allergy status and patient label Private patients: require a signature from the referring Doctor to the Pain Service Neuraxial opioid administration information Naloxone prescription OR standing order affixed Record of naloxone administration Management guidelines Contact details
6 Documentation of the administration of an opioid via the neuraxial route: Prescriber to complete patient allergy section in full Below is an EXAMPLE of documenting the administration of an neuraxial opioid Handwrite patient details or affix patient label (First prescriber to check patient label is correct) Private patients: require a signature from the referring Doctor to the Pain Service Spinal /03/13 09:00 Morphine PSmith SMITH micrograms The frequency of observations (hourly for 6 hours or hourly for 12 hours) must be determined by the medical officer who administered the opioid dose
7 Naloxone prescription: Naloxone is indicated for SEDATION SCORE 3 (difficult to rouse or unresponsive) OR SEDATION SCORE 2 (constantly drowsy unable to stay awake) and a RESPIRATORY RATE LESS THAN OR EQUAL TO 5 breaths per minute. 01/03/ Naloxone IV X 4 micrograms 2-3 minutely PSmith SMITH This section MUST be completed in full OR a sticker affixed which states the standing order PRIOR to any administration of naloxone.
8 Record of naloxone administration and neuraxial opioid management guidelines: 2/3/13 2/3/13 2/3/13 2/3/13 08:30 08:33 08:36 08: micrograms 100 micrograms 100 micrograms 100 micrograms Plambert Plambert Plambert Plambert TBuckley TBuckley TBuckley TBuckley
9 Clinical Review & Rapid Response Criteria: The back page of the chart displays instructions explaining how to make a clinical review or a rapid response These instructions incorporate track and trigger colour zones (from the Between the Flags Program) to detect the deteriorating patient
10 Clinical Review Criteria:
11 Rapid Response Criteria:
12 Managing neuraxial opioid adverse effects:
13 Naloxone given Observations: A patient label must be affixed or details written on each page that records observations Pain assessment: record R for rest and M for movement M M M R R R A sedation score or a respiratory rate in the yellow zone requires a Clinical Review by the Acute Pain Service (or equivalent medical officer) no no no no A sedation score or a respiratory rate in the red zone requires a Rapid Response to be initiated AND contact the Acute Pain Service (or equivalent medical officer) yes no no no Nausea or vomiting assessment Pruritus assessment Comments for free text
14 Standardisation of this chart promotes best practice in pain assessment and management of adverse effects in those patients who have received an opioid via the neuraxial route. Comments or questions can be directed to your implementation officer or the project leaders Emily Edmonds or Jenni Johnson (contact details introduction slide) The feedback register can be located on the ACI website: 14
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