Download PROT Opioid Tolerant Adult Pain

(31251) PROT Opioid Tolerant Adult Pain
Diagnosis
Allergies
Consults
 Consult to Pain Management Physician
Nursing
 Assess and Document
Reason for Consult [___________________].
Indicate the physician group [____________________]. Staff to
call consult(s), add to the treatment team, and update the order
with date and time of the call placed.
 Insert Peripheral Line
1. Assess and document pain rating, sedation level and
respiratory rate every 2 hours.
2. Assess and document pain rating, sedation level and
respiratory rate 30 minutes following each administration of
pain medication or after change in PCA dose.
3. Include continuous oximetry and/or spot checks.
4. If pain is mild (less than or equal to 4/10) for 24 hrs and
patient is not receiving PCA, assess and document every 4
hours.
1. When tolerating clear liquids. (See Bowel Management
Medication Section).
2. Begin if no bowel movement within 24 hours.
3. If impacted call physician for orders.
Nurse to insert and maintain peripheral line.
Respiratory
 Oxygen
PRN to keep SaO2 greater than 90%.
 Begin Bowel Management Program
 Oximetry – Continuous
Continuous for patients receiving PCA opioid analgesia.
Suggested for elderly and debilitated patients and those with
sleep apnea or cardiopulmonary issues.
Medications - IV Fluid
 NaCl 0.9% IV infusion 1000 mL
CONDITIONAL, Intravenous, Rate: [ 25
] mL/hr.
- Start if no other maintenance IV fluid is currently ordered and
needed to maintain line patency.
- Nurse to modify this order to indicate a frequency of
CONTINUOUS when order is started.
-Discontinue when PCA is discontinued.
Provider Initials
Page 1 of 7
Patient Name _________________________________________
Medical Record # _________________ Date of Birth _________
Date of Surgery/Admission ______________________________
PROVIDER’S ORDERS
06/05/2012
(31251) PROT Opioid Tolerant Adult Pain
Patient Controlled Analgesia (Single Select Section)
 morphine PCA
PATIENT CONTROLLED ANALGESIA, Intravenous.
Loading Dose: [ ] mg (suggested dose 4-6 mg for 1 dose)
PCA bolus dose: [ ] mg (suggested dose 2-4 mg).
Lockout interval: [ ] min (suggested interval 10 min)
Continuous rate: [ ] min (suggested rate 1-2 mg/hr)
Four hour dose limit: [ ] mg (suggested max 30 mg)
Discontinue for severe pruritus, nausea, or respiratory
depression. Patient should not receive additional opioids while
on PCA.
Nurse to discontinue PCA on
 POD # [
 date [
]
].
Nurse to begin pain management order(s) as written after PCA is
discontinued. Release order(s) if they are Signed and Held.
After 4 hours, if patient persistently complains of inadequate
analgesia, check pump for malfunction, verify pump settings
with orders and assess integrity of IV site.
If IV is patent and PCA functioning properly, increase
incremental PCA bolus dose setting by (increase one time only):
 50% (round down to nearest tenth of mg).
[
] mg.
If patient becomes overly sedated with single PCA bolus dose,
turn off continuous infusion and decrease PCA bolus dose by
50%.
Provider Initials
Page 2 of 7
Patient Name _________________________________________
Medical Record # _________________ Date of Birth _________
Date of Surgery/Admission ______________________________
PROVIDER’S ORDERS
06/05/2012
(31251) PROT Opioid Tolerant Adult Pain
 HYDROmorphone PCA
PATIENT CONTROLLED ANALGESIA, Intravenous
Loading Dose: [ ] mg (suggested dose 0.4-0.6 mg for 1 dose)
PCA bolus dose: [ ] mg (suggested dose 0.2-0.4 mg)
Lockout interval: [ ] min (suggested 10 minutes)
Continuous rate: [ ] min (suggested rate 0.2 mg/hr)
Four hour dose limit: [ ] mg (suggested max 6 mg)
Discontinue for severe pruritis, nausea, or respiratory depression.
Patient should not receive additional opioids while on PCA.
Nurse to discontinue PCA on
 POD # [
 date [
]
].
Nurse to begin pain management order(s) as written after PCA is
discontinued. Release order(s) if they are Signed and Held.
After 4 hours, if patient persistently complains of inadequate
analgesia, check pump for malfunction, verify pump settings with
orders and assess integrity of IV site.
If IV is patent and PCA functioning properly, increase
incremental PCA bolus dose setting by (increase one time only):
 50% (round down to nearest tenth of mg).
[
] mg.
If patient becomes overly sedated with single PCA bolus dose,
turn off continuous infusion and decrease PCA bolus dose by
50%.
For IV Narcotic Analgesics – Select 1 medication from each group: Q1H PRN & Q2H PRN
IV Narcotic Analgesics Q1H PRN (Single Select Section)
Q1H PRN x 4 hours, Intravenous, Dose: 4-6 mg, PRN for severe
 morphine IV
pain.
- MAXIMUM DURATION OF 4 HOURS
- If pain not controlled (greater than 4 out of 10) at maximum
dose for 2 doses call physician for further orders.
Q1H PRN x 4 hours, Intravenous, Dose: 2-4 mg, PRN for severe
 morphine IV – for patients greater than 65 y.o. or
pain.
debilitated
- MAXIMUM DURATION OF 4 HOURS
- If pain not controlled (greater than 4 out of 10) at maximum
dose for 2 doses call physician for further orders.
Provider Initials
Page 3 of 7
Patient Name _________________________________________
Medical Record # _________________ Date of Birth _________
Date of Surgery/Admission ______________________________
PROVIDER’S ORDERS
06/05/2012
(31251) PROT Opioid Tolerant Adult Pain
 HYDROmorphone (DILAUDID IV
 HYDROmorphone (DILAUDID) IV – for patients
greater than 65 y.o. or debilitated
Q1H PRN x 4 hours, Intravenous, Dose: 0.4-0.6 mg, PRN for
severe pain.
- MAXIMUM DURATION OF 4 HOURS
- If pain not controlled (greater than 4 out of 10) at maximum
dose for 2 doses call physician for further orders.
Q1H PRN x 4 hours, Intravenous, Dose: 0.2-0.4 mg, PRN for
severe pain.
- MAXIMUM DURATION OF 4 HOURS
- If pain not controlled (greater than 4 out of 10) at maximum
dose for 2 doses call physician for further orders.
IV Narcotic Analgesics Q2H PRN (Single Select Section)
Q2H PRN, Intravenous, Dose: 4-6 mg, PRN for severe pain.
 morphine IV
- Begin when Q1H PRN order is discontinued.
- If pain not controlled (greater than 4 out of 10) at maximum
dose for 2 doses call physician for further orders.
Q2H PRN, Intravenous, Dose: 2-4 mg, PRN for severe pain.
 morphine IV – for patients greater than 65 y.o. or
- Begin when Q1H PRN order is discontinued.
debilitated
- If pain not controlled (greater than 4 out of 10) at maximum
dose for 2 doses call physician for further orders.
Q2H PRN, Intravenous, Dose: 0.4-0.6 mg, PRN for severe pain.
 HYDROmorphone (DILAUDID) IV
- Begin when Q1H PRN order is discontinued.
- If pain not controlled (greater than 4 out of 10) at maximum
dose for 2 doses call physician for further orders.
Q2H PRN, Intravenous, Dose: 0.2-0.4 mg, PRN for severe pain.
 HYDROmorphone (DILAUDID) IV – for patients
- Begin when Q1H PRN order is discontinued.
greater than 65 y.o. or debilitated
- If pain not controlled (greater than 4 out of 10) at maximum
dose for 2 doses call physician for further orders..
IV Anti-inflammatory (Single Select Section)
Q6H, Intravenous, Dose: 30mg
 ketorolac (TORADOL) IV
MAXIMUM DURATION OF 5 DAYS
- Do not administer if recent history of GI bleed or renal
insufficiency (serum creatinine >1.8).
- Switch to ibuprofen when tolerating PO, if ordered.
 ketorolac (TORADOL) IV – for patient greater than Q6H, Intravenous, Dose: 15 mg
MAXIMUM DURATION OF 5 DAYS
65 y.o. or less than 50 kg
- Do not administer if recent history of GI bleed or renal
insufficiency (serum creatinine >1.8).
- Switch to ibuprofen when tolerating PO, if ordered.
Provider Initials
Page 4 of 7
Patient Name _________________________________________
Medical Record # _________________ Date of Birth _________
Date of Surgery/Admission ______________________________
PROVIDER’S ORDERS
06/05/2012
(31251) PROT Opioid Tolerant Adult Pain
Oral Anti-inflammatory
 ibuprofen (MOTRIN; ADVIL) PO
CONDITIONAL, Oral, Dose : 600 mg
- Begin after ketorolac (TORADOL) is discontinued.
- Do NOT give within 6 hours of ketorolac (TORADOL), if both
ordered.
- Nurse to modify this order to indicate a frequency of Q6H when
order is started.
Oral Narcotic Analgesics (Single Select Section)
 oxyCODONE PO
 oxyCODONE-acetaminophen (5-325 mg)
(PERCOCET) PO
 HYDROcodone-acetaminophen (7.5-325 mg)
(NORCO) PO
 HYDROcodone-acetaminophen (10-325 mg)
(NORCO) PO
Oral Non-Narcotic Analgesics (Select Both)
 acetaminophen (TYLENOL) PO - Scheduled
 acetaminophen (TYLENOL) PO - PRN
Opioid Antagonist
 naloxone (NARCAN) IV
Q4H PRN, Oral, Dose: 1-2 tablets, PRN for moderate pain.
Maximum dose of acetaminophen is 4000 mg from all sources in
24 hours.
Q4H PRN, Oral, Dose: 1-2 tablets, PRN for moderate pain.
Maximum dose of acetaminophen is 4000 mg from all sources in
24 hours..
Q4H PRN, Oral, Dose: 1-2 tablets, PRN for moderate pain.
Maximum dose of acetaminophen is 4000 mg from all sources in
24 hours..
Q4H WHILE AWAKE, Oral, Dose: 650 mg
- Discontinue if acetaminophen containing opioid is ordered or
pain is mild (less than or equal to 4 out of 10) for 24 hours.
- Maximum dose of acetaminophen is 4000 mg from all sources
in 24 hours.
CONDITIONAL, Oral, Dose: 650 mg, PRN for mild pain.
- Begin when scheduled acetaminophen is discontinued.
- Nurse to modify this order to indicate a frequency of Q4H PRN
when order is started.
- Maximum dose of acetaminophen is 4000 mg from all sources
in 24 hours.
Q3 MIN PRN, Intravenous, Dose: 0.08 mg, PRN if respiratory
rate is < 8/min or patient is difficult to arouse.
- Give 0.08 mg (0.2 mL) every 3 minutes and repeat up to 0.4 mg
total (1 mL) or until patient is responsive to physical stimulation
and is able to take deep breaths.
- Continue to observe, if no response within 3 minutes of
administration of 0.4 mg total, repeat dose (0.4 mg as
administered previously) and notify physician STAT.
Provider Initials
Page 5 of 7
Patient Name _________________________________________
Medical Record # _________________ Date of Birth _________
Date of Surgery/Admission ______________________________
PROVIDER’S ORDERS
Q4H PRN, Oral, Dose: 5-10 mg, PRN for moderate pain.
06/05/2012
(31251) PROT Opioid Tolerant Adult Pain
IV Antiemetics (Select All 3)
 ondansetron (ZOFRAN) IV
Q6H PRN, Intravenous, Dose: 4 mg, PRN for nausea/vomiting.
This medication is 1st choice for control of nausea/vomiting.
If ineffective, causing adverse effects or patient preference,
consider droperidol.
Q6H PRN, Intravenous, Dose 0.625 mg PRN for nausea/vomiting
if ondansetron ineffective. Maximum dose 2.5 mg in 24 hours.
If ineffective, causing adverse effects or patient preference,
consider prochlorperazine.
Q6H PRN, Intravenous, Dose: 10 mg, PRN for nausea/vomiting.
This medication is 3rd choice for control of nausea/vomiting.
If ineffective, causing adverse effects or patient preference, then
contact physician.
 droperidol (INAPSINE) IV
 prochlorperazine (COMPAZINE) IV
Oral/Rectal Antiemetics
 prochlorperazine (COMPAZINE) PO
Q6H PRN, Oral, Dose: 10 mg, PRN for nausea/vomiting
 prochlorperazine (COMPAZINE) PR
Q12H PRN, Rectal, Dose: 25 mg, PRN for nausea/vomiting
IV Antihistamines (Single Select Section)
 diphenhydrAMINE (BENADRYL) IV
Q6H PRN, Intravenous, Dose: 25 mg, PRN for itching.
 diphenhydrAMINE (BENADRYL) IV – for
Q6H PRN, Intravenous, Dose: 12.5 mg, PRN for itching.
patient greater than 65 y.o. or less than 50 kg
Oral Antihistamines (Single Select Section)
 diphenhydrAMINE (BENADRYL) PO
Q6H PRN, Oral, Dose: 25 mg, PRN for itching.
 diphenhydrAMINE (BENADRYL) PO – for
Q6H PRN, Oral, Dose: 12.5 mg, PRN for itching.
patient greater than 65 y.o. or less than 50 kg
Bowel Management (Select ALL)
 docusate-senna (50-8.6mg) (SENOKOT-S)
PO
 milk of magnesia PO/NG – one time
 milk of magnesia PO/NG - PRN
BID, Oral, Dose: 1-4 tablets. Begin when tolerating clear liquids.
Initial dose: 2 tablets for 2 doses. If no results, increase to 3
tablets for 2 doses. If no results, increase to 4 tablets. If greater
than 2 bowel movements in 24 hours at any point, reduce to 1
tablet.
BEDTIME, Oral, Dose: 30 mL. This medication is first choice if
no bowel movement within 24 hours of initiation of SENOKOTS, give one dose.
BEDTIME PRN, Oral, Dose: 30-60 mL, PRN constipation. Start
48 hours of initiation of SENOKOT-S.
Provider Initials
Page 6 of 7
Patient Name _________________________________________
Medical Record # _________________ Date of Birth _________
Date of Surgery/Admission ______________________________
PROVIDER’S ORDERS
06/05/2012
(31251) PROT Opioid Tolerant Adult Pain
 lactulose (KRISTALOSE) PO/NG
TID PRN, Oral/NG Tube, Dose: 20 g, PRN for constipation. This
medication is second choice if no bowel movement by morning
following administration of milk of magnesia administration and
impaction is ruled out, give lactulose. Dissolve powder in 4
ounces of water.
ONE TIME PRN, Oral/NG Tube, Dose: 120 mL, PRN for
constipation. This medication is third choice if no bowel
movement within 24 hours of lactulose administration and
impaction is ruled out, give magnesium citrate. May repeat
magnesium citrate once. If magnesium citrate is ineffective
contact physician.
ONE TIME PRN, Rectal, Dose: 10 mg, PRN for constipation.
Give if stool is in large bowel or rectum and not impacted.
 magnesium citrate PO/NG
 bisacodyl (DULCOLAX) PR
Interdisciplinary Consult
 Integrative Medicine Consult
For acupuncture eval and treat
Is patient aware of consult  Yes
 No
Reason for consult [
Primary problem or diagnosis [
When is discharge likely [
].
].
].
Additional Orders
______________________________
Provider Signature
Provider Initials
_________
Time
Page 7 of 7
Patient Name _________________________________________
Medical Record # _________________ Date of Birth _________
Date of Surgery/Admission ______________________________
PROVIDER’S ORDERS
________
Date
06/05/2012