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)
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 0.8 2 mg PCA Dose 1 mg 0.5 2 mg 0.4 1.5 mg 4 Hour Limit 20 mg 20 30 mg 15 20 mg Continuous Rate *CAUTION* 1 mg/hr 0.5 2 mg/hr 0.4 1.5 mg/hr Loading Dose 0.4 mg 0.3-0.5 mg 0.2 0.4 mg PCA Dose 0.2 mg 0.1 0.3 mg 0.1 0.2 mg 4 Hour Limit 4 mg 4 6 mg 3 4.5 mg Continuous Rate *CAUTION* 0.2 mg/hr 0.2-0.4 mg/hr 0.15-0.3 mg/hr Loading Dose 25 mcg 10 30 mcg 7 20 mcg PCA Dose 10 mcg 5 20 mcg 4 15 mcg 4 Hour Limit 300 mcg 300 500 mcg 225 375 mcg Continuous Rate *CAUTION* 5 mcg/hr 5 10 mcg/hr 4 8 mcg/hr Loading Dose 25 mg 20-30 mg 15-20 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 150-300 mg 100-200 mg Continuous Rate *CAUTION* 10 mg/hr 10-20 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)
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)
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) 500 1000 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) 15 30 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) 80 160 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)
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) 0.5 1 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) 500 1000 mg PO every 4 hours PRN fever (Do not exceed 4,000 mg in 24 hours), if ineffective/contraindicated use: Ibuprofen (Motrin) 200 400 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: