Download 3. contraindications 1

INTERNAL ONLY
STANDING ORDER
EMERGENCY DEPARTMENTS
MORPHINE SULFATE –
Intravenous administration by Accredited Emergency Nurses
for moderate to severe pain
POLICY STATEMENT
This order may only be activated under the specific circumstances set out in the section
“Indications” and provided there are no contraindications present.
The administering nurse must be accredited to administer the drug and record the
administration in ink on the once only section of the medication chart. This order must be
checked and signed by a medical officer within 24 hours, and preferably within 4
hours, of activation of the standing order.
This standing order is only valid until the date noted by the Drug and Quality Use of
Medicines Committee under the heading "Effective To:" at the end of this document.
1.
NURSING ACCREDITATION REQUIREMENTS
Accredited Registered Nurses employed within SESLHD Emergency Departments (ED) who are
working in a extended practice nurse or Advanced Clinical Nurse (ACN) capacity must have at
least a minimum of two (2) years emergency / critical care experience and must be able to work at
a minimum of resuscitation level or above (i.e. triage / clinical initiatives nurse) and/or as approved
by the ED Nurse Manager.
2.
INDICATIONS
Adult patients (16 years of age and over) who present to SESLHD Emergency Department (ED) in
moderate to severe pain with verbal numerical rating scale of equal to or greater than five (5).
CONTRAINDICATIONS 1
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REV 1
Less than16 years of age
Haemodynamically unstable (meets PACE / Between The Flag criteria2)
Acute pain with a verbal numerical rating scale of less than 5
Known hypersensitivity to morphine or other opioids
Acute or severe bronchial asthma or other obstructive airways disease
Severe CNS depression
Diabetic acidosis where there is a danger of coma
Severe liver disease or incipient hepatic encephalopathy
Following biliary tract surgery or surgical anastomosis
Gastrointestinal obstruction or suspected surgical abdomen
Monoamine oxidase (MAO) inhibitors within the previous fourteen days
Cardiac arrhythmias; heart failure secondary to pulmonary disease
Acute alcoholism or delirium tremens
Head injuries (Glasgow Coma Scale less than 15)
Brain tumour; raised intracranial or cerebrospinal pressure
Convulsive states such as status epilepticus
Tetanus or strychnine poisoning
October 2014
Page 1 of 5
INTERNAL ONLY
STANDING ORDER
EMERGENCY DEPARTMENTS
MORPHINE SULFATE –
Intravenous administration by Accredited Emergency Nurses
for moderate to severe pain
PRECAUTIONS 1
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5.
Respiratory depression or impairment
Bradycardia
CNS depression
Drug dependence and tolerance
Hypotensive effect
Supraventricular tachycardias
Acute abdominal condition
Convulsions
Hepatic impairment
Renal impairment
Elderly
Pregnancy (Category C) – morphine crosses the placenta and is associated with foetal
CNS effects
Lactation – morphine is excreted in milk and breastfeeding is not recommended
ACTIONS/MONITORING REQUIRED
Pre administration:
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Assessment of previous pain treatments utilised i.e. over the counter and/or prescription
drugs
The patient must have a cannula insitu and be laying down
A full set if vitals (heart rate, blood pressure, respiration rate, temperature, Glasgow Coma
Scale (GCS) and pain score) must be taken prior to administration of morphine sulfate.
10 mg / 1 mL morphine sulfate ampoules are diluted with 9 mL of sodium chloride 0.9% to
make concentration of 1 mg / mL
OR
5 mg / 1 mL morphine sulfate ampoules are diluted with 4 mL of sodium chloride 0.9% to
make concentration of 1 mg / mL
All syringes must be labelled with a medication label indicating morphine and the dilution.
Documentation:
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Document patient observations including the patient’s pain score on the ED Standard Adult
General Observation (SAGO) Chart and/or electronically within Firstnet.
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The administering nurse must record the administration in ink on the ‘once-only’ section of
the National Inpatient Medication Chart (NIMC) as Emergency Department Standing Order
(i.e. “ED SO”) plus print and sign their name.
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The EDSO drug order must be countersigned by the medical officer that subsequently
assesses and treats the patient within 4 hours.
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Accountable Drug Register documentation must be completed i.e. when documenting in the
S8 drug book, the ED Medical Director’s name followed by ‘EDSO’ next to it to indicate this
is a standing order.
REV 1
October 2014
Page 2 of 5
INTERNAL ONLY
STANDING ORDER
EMERGENCY DEPARTMENTS
MORPHINE SULFATE –
Intravenous administration by Accredited Emergency Nurses
for moderate to severe pain

The signatures of the administering nurse and nurse checking the medication must be
clearly documented both in the Accountable Drug Register and on the NIMC and includes
completing the date, time, drug, dose, route and time of administration sections.
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The administering nurse must record in the patient’s progress notes the administration and
effect of the medication.
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Drugs must be checked and ordered according to hospital policy and adhering to the
Ministry of Health Policy Medication Handling in NSW Public Health Facilities PD2013_043.
Post administration:
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Evaluate and document therapeutic response to pain via numerical or visual analogue pain
score
 Re-assessment of pain within 3-5 minutes of administration of each 2.5 mg dose.
 Re-assessment of patient is to occur after each IV bolus including full set of vital signs
(heart rate, blood pressure, respiration rate, temperature, Glasgow Coma Scale (GCS) and
pain score).
 Ongoing monitoring of respiratory rate
Senior medical review must be obtained if any of the following occur:
1. Respiratory rate less than 10 breaths a minute
2. SpO2 <92%
3. Systolic blood pressure <100mmHg
4. Heart rate <50bpm
5. GCS < 14
6. Sedation score >1
 Notify a medical officer if patient meets PACE / Between The Flag criteria2
 Monitor for side effects and consider anti-emetics if nausea / vomiting develops.
 Warn patient of possible sedation and not to drive or operate machinery
Sedation scoring
Measuring patient sedation in relation to the medication discussed within the document, the
following tool is to be used:
0
1
2
Wide awake
Easy to rouse
Constantly drowsy, unable to stay awake
3
Yellow Zone: Cease administration. Given high-flow oxygen, complete primary survey, alert
attending emergency medical officer. If patient respiratory rate less than or equal to 5
breathes per minute, activate emergency call buzzer.
Difficult to rouse or unresponsive
Red Zone: Activate emergency call buzzer, complete primary survey, administer high-flow
oxygen.
REV 1
October 2014
Page 3 of 5
INTERNAL ONLY
STANDING ORDER
EMERGENCY DEPARTMENTS
MORPHINE SULFATE –
Intravenous administration by Accredited Emergency Nurses
for moderate to severe pain
6.
PROTOCOL/ADMINISTRATION GUIDELINES:
Caution: CHECK for allergies and/or contraindications
Drug
Dose
Route
16 to 65 years:
Morphine
Sulfate
(solution for
injection)
2.5 mg – 10 mg
over 65 years:
1 mg – 5 mg
Intravenous (IV)
over 1 to 2
minutes
Frequency
every 3 to 5 minutes for pain
score ≥5 until a maximum dose
of 10 mg has been
administered
every 3 to 5 minutes for pain
score ≥5 until a maximum dose
of 5 mg has been administered
Solution for injection should be clear, colourless to slightly yellow.
Sodium chloride 0.9% 5 mL flush should be administered IV after each morphine dose.
Unused portions of morphine are to be discarded immediately once the patient is pain free or if it
has been greater than 5 minutes since the last dose.
The morphine must be discarded by the same two employees who prepared the medication (RN,
MO or pharmacist) and recorded in the drug register.
7.
POTENTIAL ADVERSE EFFECTS/INTERACTIONS:
Most common side effects:
 Constipation,
 Lightheadedness, dizziness, sedation / drowsiness,
 Nausea, vomiting,
 Sweating, dysphoria and euphoria.
Less frequent side effects:
 Cardiovascular. Flushing of the face, chills, tachycardia, bradycardia, palpitations,
syncope, hypotension and hypertension.
 Central nervous system. Weakness, headache, restlessness, anxiety, agitation, tremor,
uncoordinated muscle movements, insomnia, dizziness, vertigo, delirium, confusional
symptoms and occasionally hallucinations.
 Gastrointestinal. Dry mouth, anorexia, , cramps, laryngospasm, colic, taste alterations and
biliary tract cramps and biliary spasm.
 Genitourinary. Urinary retention or hesitancy, ureteric spasm, reduced libido or potency
 Endocrine. Hyponatraemia, hyperglycaemia.
 Visual disturbances. Blurred vision, nystagmus, diplopia and miosis
 Allergic. Pruritus, urticaria, other skin rashes including contact dermatitis and oedema.
Allergic reactions may be due to histamine release and may be more frequent in asthmatic
patients. Anaphylactic reactions following intravenous injection have been reported rarely
 Local effects. Pain at injection site or local tissue irritation
REV 1
October 2014
Page 4 of 5
INTERNAL ONLY
STANDING ORDER
EMERGENCY DEPARTMENTS
MORPHINE SULFATE –
Intravenous administration by Accredited Emergency Nurses
for moderate to severe pain
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Dependence/ tolerance - with long term use.
Withdrawal (abstinence) syndrome -
Interactions:
 CNS depressants - including other opioids, sedatives, hypnotics, general anaesthetics,
tranquilisers, phenothiazines and alcohol
 Antihypertensives
 Muscle relaxants
 MAO Inhibitors
 Anticoagulants
 Diuretics
 Amphetamines
 Metoclopramide
 Delayed gastric emptying may delay absorption of orally administered drugs
 Anticholinergic agents increase risk of constipation
8.
REFERENCES:
1. MIMMS Online. Morphine Sulphate. 2014 [cited 25/8/14] Available from:
https://www.mimsonline.com.au.acs.hcn.com.au/Search/FullPI.aspx?ModuleName=Produc
tInfo&searchKeyword=Morphine+sulfate&PreviousPage=~/Search/QuickSearch.aspx&Sear
chType=&ID=3790001_2
2. SESLHD Patient with Acute Condition for Escalation (PACE): Management of the
Deteriorating Adult and Maternity Inpatient SESLHD/PR283.
http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Other/SESL
HDPR283-PACE-MgtOfTheDeterioratingAdultMaternityInpatient.pdf
3. Ministry of Health Policy Medication Handling in NSW Public Health Facilities PD2013_043
http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_043.pdf
Authorised by:
Name
Designation
Professor
Gordian Fulde
Emergency/ Critical
Care Stream Director
Endorsed by:
Name
Designation
Signature
Signature
Chair, SESLHD
D&QUM Committee
REV 1
Date
Endorsed
Date
Effective To:
30 November
2015
October 2014
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