Downtime Orders: PCA Acute Pain

Transcription

1 Orders that contain the following are INVALID: Page 1 of 6 Downtime Orders: PCA Acute Pain Standard pathway care: ( ) checked box represents standard care Individualized care: Add ( ) to blank box ( ) Line out text and for pre-checked standard that does not apply; initial, date and time. For substitutions, write desired order on same line as that which it replaces. Date: Time: Anticipated LOS: Weight: kg Allergies: Patient Care Vital Signs Q4H, First vital signs within 15 minutes of initiation of PCA therapy, then Q4H while on PCA, if any PCA dose or rate change check vital signs within 15 minutes. RN to discontinue this order when the PCA is discontinued. Respiration Rate Q2H, First vital signs within 15 minutes of initiation of PCA therapy, then every 2 hours while on PCA, if any PCA dose or rate change check vital signs within 15 minutes. RN to discontinue this order when the PCA is discontinued. Pain Score Q4H, Per pain policy. RN to discontinue this order when the PCA is discontinued. Conditional Patient Care Urine Action Bladder Scan, If patient is unable to void, perform a bladder scan and contact attending physician for orders (eg. catheterize vs. fluid flush). RN to discontinue this order when the PCA is discontinued. Notify MD/HO/APRN Instructions: Call If: Resp Rate, BP, Heart Rate, SpO2 (PCA/Epidural Vital Signs Outside of Standard) parameters; Mental status changes; Withdrawal; Excessive Pain. RN to discontinue this order when the PCA is discontinued. Monitoring Pulse Oximetry Continuous, Use (PCA Vital Signs Outside of Standard) parameters. Continuous, For the first 4 hours of the initial infusion, and the first 4 hours immediately following an increase in dosage. (See PCA Vital Signs/SaO2 Guidelines). Apnea/Bradycardia Monitor Use (PCA Vital Signs Outside of Standard) parameters. Medications Free Text Order No additional narcotics or sedatives may be given while the PCA medications are actively infusing unless approved by the service managing the PCA Free Text Order PCA to start in surgery. Deliver to PACU. Free Text Order If admitted to an ICU, PCA changes may be made by an intensivist. PCA morphine morphine PCA loading dose Give 0.1 mg/kg IV On Call, SYR, Duration: 4 hr Give loading dose from PCA Syringe. morphine Pediatric Standard PCA. PCA Dose + Continuous Infusion, mg, PATIENT to Administer PCA Doses Lockout Interval = 5 minutes, mg/hr. mg,, IV Order Changes By Specify, See Details morphine PCA

2 Orders that contain the following are INVALID: Page 2 of 6 INCREASED DOSING BASED ON RESPONSE: If patient has unrelieved Pain greater than [ ] / 10 on pain assessment scale (policy > 4) has NO clinical signs of opioid over-sedation has received more than [ ] PCA boluses/hour for [ ] consecutive hours THEN increase PCA setting as follows: (ALL ABOVE BLANKS MUST BE FILLED IN) Step 1: Increase PCA dose to: mg Lockout interval: minutes Continuous rate: mg/hour Maximum 1 hour limit: mg/hour Step 2: Increase PCA dose to: mg Continuous rate: mg/hour Maximum 1 hour limit: mg/hour DECREASED DOSING BASED ON RESPONSE: If patient is over-sedated or is awake and comfortable and if PCA doses delivered are less than 2 per hour for 3 consecutive hours, decrease PCA settings as follows: PCA dose decrease: mg Continuous Rate decrease: mg/hour Maximum 1 hour limit: mg/hour morphine Pediatric Standard PCA morphine infusion: 55 mg NS (PCA): PCA Dose + Continuous Infusion, mg, PATIENT to Administer PCA Doses Lockout Interval = 5 minutes, mg/hr. mg,, IV Order Changes By Intensivist, See Details Note: For patients less than 10 kg morphine Neonatal/<10 kg D5W PCA D5W (PCA): PCA Dose + Continuous Infusion, mg, Lockout Interval = 5 minutes, mg/hr. mg,, IV Order Changes By Specify, See Details, Routine Total Volume: 30 ml morphine 5 mg/1 ml NS PCA morphine infusion: 250 mg PCA HYDROmorphONE HYDROmorphone PCA loading dose Give 15 mcg/kg IV On Call, SYR, Duration: 4 hr Give loading dose from PCA Syringe. HYDROmorphONE Pediatric Standard PCA NS (PCA): PCA Dose + Continuous Infusion, mcg, Lockout Interval = 5 minutes, mcg/hr. mcg,, IV, See Details, Routine Total Volume: 45 ml

3 Orders that contain the following are INVALID: Page 3 of 6 Note: For patients less than 10 kg HYDROmorphONE Neonatal/<10 kg PCA NS (PCA): PCA Dose + Continuous Infusion, mcg, Lockout Interval = 5 minutes, mcg,, IV Order Changes By Specify, See Details, Routine Total Volume: 30 ml PCA Fentanyl fentanyl PCA loading dose Give 1.5 mcg/kg IV On Call, SYR, Duration: 4 hr Give loading dose from PCA Syringe. fentanyl Pediatric Standard PCA. PCA Dose + Continuous Infusion, mcg, PATIENT to Administer PCA Doses Lockout Interval = 5 minutes, mcg/hr. mcg,, IV Order Changes By Specify, See Details Fentanyl PCA INCREASED DOSING BASED ON RESPONSE: If patient has unrelieved Pain greater than [ ] / 10 on pain assessment scale (policy > 4) has NO clinical signs of opioid over-sedation has received more than [ ] PCA boluses/hour for [ ] consecutive hours THEN increase PCA setting as follows: (ALL ABOVE BLANKS MUST BE FILLED IN) Step 1: Increase PCA dose to: mcg Lockout interval: minutes Continuous rate: mcg/hour Maximum 1 hour limit: mcg/hour Step 2: Increase PCA dose to: mcg Continuous rate: mcg/hour Maximum 1 hour limit: mcg/hour DECREASED DOSING BASED ON RESPONSE: If patient is over-sedated or is awake and comfortable and if PCA doses delivered are less than 2 per hour for 3 consecutive hours, decrease PCA settings as follows: PCA dose decrease: mcg Continuous Rate decrease: mcg/hour Maximum 1 hour limit: mcg/hour Note: For patients less than 10 kg Fentanyl Neonatal/<10 kg D5W PCA D5W (PCA): PCA Dose + Continuous Infusion, mcg, Lockout Interval = 5 minutes, mcg/hr. mcg,, IV Order Changes By Specify, See Details, Routine Total Volume: 30 ml

4 Orders that contain the following are INVALID: Page 4 of 6 PCA Midazolam Midazolam 0.5 mg/1 ml D5W PCA midazolam infusion: Give 15 mg D5W (PCA): mg, Lockout Interval = 15 minutes, mg/hr. mg,, IV Order Changes By Specify, See Order Details, Routine Midazolam 1 mg/1 ml NS PCA midazolam infusion: Give 50 mg NS (PCA): mg, Lockout Interval = 15 minutes, mg/hr. mg,, IV Order Changes By Specify, See Order Details, Routine Supplemental Analgesic Medications Note: Toradol (ketorolac): Patients 6-11 months old = Q8H, Patients 1 year or older = Q6H Toradol Give 0.5 mg/kg IV Q6H, INJ, Duration: 5 Days Give 0.5 mg/kg IV Q6H PRN pain, severe, INJ, Duration: 5 Days Give 0.5 mg/kg IV Q8H, INJ, Duration: 5 Days Give 0.5 mg/kg IV Q8H PRN pain, severe, INJ, Duration: 5 Days Note: Motrin (ibuprofen): Patients 3-5 months old = 5 mg/kg; Patients 6 months or older = 10 mg/kg. Motrin Give 10 mg/kg PO Q6H PRN pain, mild or anticipated Give 5 mg/kg PO Q6H PRN pain, mild or anticipated Give 10 mg/kg PO Q6H Give 5 mg/kg PO Q6H Tylenol Give 15 mg/kg PO Q4H PRN pain, mild or anticipated Give 10 mg/kg PO Q4H PRN pain, mild or anticipated Give 15 mg/kg PO Q6H Give 10 mg/kg PO Q6H Tylenol Give 10 mg/kg Rectally Q6H PRN pain, mild or anticipated, SUPP Give 15 mg/kg Rectally Q6H PRN pain, mild or anticipated, SUPP Give 10 mg/kg Rectally Q6H, SUPP Give 15 mg/kg Rectally Q6H, SUPP

5 Orders that contain the following are INVALID: Page 5 of 6 Side Effect Management Narcan Give 0.01 mg/kg IV PRN respiratory depression, INJ RR < or below physiologic norms. For apnea/severe hypoventilation. Call prescriber STAT. May repeat this dose one time in 2 to 3 minutes. Stop PCA infusion. Zofran Give 0.1 mg/kg IV Q6H PRN nausea or vomiting, INJ Max dose = 4 mg. Call provider if Nausea/Vomiting not controlled by medication. Benadryl Give 0.5 mg/kg IV Q4H PRN itching, INJ Max dose = 50 mg. Call provider if Pruritis not controlled by medication. Give 1 mg/kg IV Q4H PRN itching, INJ Max dose = 50 mg. Call provider if Pruritis not controlled by medication. Note: ZyrTEC (cetirizine): Patients 6 months - 5 years old = 2.5 mg; Patients 6 years or older = 5-10 mg/day as a single dose or divided into 2 doses ZyrTEC Give 2.5 mg PO QDay Give 5 mg PO BID Give 10 mg PO QDay Naloxone 2 mg/250 ml NS Continuous Infusion NS: IV, Routine Total Volume: 250 ml Colonic Purging Agents Note: MiraLax Dosing = 4 grams (1 to 4 years old); 8.5 grams (5 to 12 years old); 17 grams (over 12 years old). MiraLax Give 4 g PO QDay Give 8.5 g PO QDay Give 17 g PO QDay Note: Senna Dosing = 4.4 mg (2 to 5 years old); 8.8 mg (5 to 12 years old); 1 tablet (8.6mg) (over 12 years old). senna Give 4.4 mg PO QDay, SYRUP Give 8.8 mg PO QDay, SYRUP Give 8.6 mg PO QDay, TAB Respiratory Incentive Spirometry Q2H WA Q4H WA Q2H Q4H

6 Orders that contain the following are INVALID: Page 6 of 6 Oxygen Therapy O2 Delivery Route/Device Best Tolerated Means, Goal is to maintain sats above 90%. Immediate O2 for sats less than 85%. For sats 85-90%: wait 5 minutes, then give supplemental O2 if sats don't increase. Attempt to wean from O2 q 2 hrs to keep sats at 90 Oxygen Therapy O2 Delivery Route/Device Best Tolerated Means, For Cyanotic Heart Disease, oxygen to keep O2 saturations between 70 to 90%. Consults Consult Pain/Palliative Care Consult Specify Provider Signature: Date: Time: