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(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