Download Ketamine Infusion (adult)

MRN
FAMILY NAME
GIVEN NAME
D.O.B. _______ / _______ / _______
ALL OBSERVATIONS MUST BE GRAPHED
LOCATION
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
{
Assess pain both at rest and with relevant movement. Document “R” for rest and “M” for movement
10
Severe pain
9
8
7
6
Moderate pain
5
4
3
Mild pain
2
1
No pain
0
{
{
Dysphoric adverse effects present
10
9
8
7
6
5
4
3
2
1
0
Yes
Yes
No
No
Cumulative dose
mg or mL (circle one)
Ketamine program checked (initial)
once per shift, on patient transfer and
on change of bag or syringe
Subcutaneous or IV cannula site
secure, no signs of inflammation
(check 8 hourly)
LOCATION / WARD
Ketamine Infusion Management Guidelines
(For detailed information regarding PCA prescribing and management refer to local hospital PCA policy)
● Observations on this form to be recorded
either 2 hourly or 4 hourly as indicated on
the prescription section of this form or more
frequently if patient’s clinical condition warrants.
- If PCA (Patient controlled analgesia) in
use, document pain scores on the PCA chart
only. Record observations according to PCA
management guidelines.
● Infusion pump settings to be checked at the
commencement of each shift, on patient transfer
and when the syringe or bag is changed.
● The cannula site (subcutaneous or
intravenous) must be checked each shift for
signs of redness, swelling or tenderness.
● Managing dysphoric effects such as
hallucinations, unpleasant dreams or visual
disturbances: contact the relevant pain service
or equivalent medical officer. A medical officer
may consider a dose reduction of the ketamine
infusion or the addition of a benzodiazepine.
(e.g. midazolam)
REFER TO YOUR LOCAL CLINICAL EMERGENCY RESPONSE SYSTEM (CERS) PROTOCOL
FOR INSTRUCTIONS ON HOW TO MAKE A CALL TO ESCALATE CARE FOR YOUR PATIENT
APPROPRIATE CLINICAL CARE FOR PATIENTS WITH YELLOW ZONE OBSERVATIONS:
•
ENSURE THAT THE ACUTE PAIN SERVICE OR EQUIVALENT MEDICAL OFFICER IS CONTACTED
YELLOW ZONE RESPONSE
IF YOUR PATIENT HAS ANY YELLOW ZONE OBSERVATIONS YOU MUST FOLLOW THE YELLOW
ZONE RESPONSE INSTRUCTIONS ON THE NSW STANDARD OBSERVATION CHARTS AND INITIATE
APPROPRIATE CLINICAL CARE AS STATED ABOVE
COMMENTS
KETAMINE INFUSION (ADULT)
Two initials for change of ketamine
program
M.O.
Managing Adverse Effects
Holes Punched as per AS2828.1: 2012
mg or mL per hour (circle one)
FEMALE
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
BINDING MARGIN - NO WRITING
INFUSION RATE
KETAMINE INFUSION (ADULT)
SMR130028
If PCA in
use,
document
pain
scores
on PCA
chart only
TIME
MALE
ADDRESS
ADDRESS
DATE
PAIN SCORE
D.O.B. _______ / _______ / _______
Facility:
¶SMRÊ-Î<6Ä
Altered Calling Criteria
M.O.
BINDING MARGIN - NO WRITING
KETAMINE INFUSION (ADULT)
MRN
GIVEN NAME
FEMALE
Holes Punched as per AS2828.1: 2012
Facility:
MALE
FAMILY NAME
130217
NH606624
NO WRITING
SMR130.028
¶SMRÊ-Î<6Ä
SMR130028
INITIAL:
Page 8 of 8
ACUTE PAIN SERVICE or equivalent medical officer CONTACT:
BUSINESS HOURS page/phone:
OUT OF HOURS page/phone:
NO WRITING
Page 1 of 8
FAMILY NAME
Attach ADR Sticker
GIVEN NAME
ALLERGIES & ADVERSE DRUG REACTIONS (ADR)
Nil known
Drug (or other)
Unknown (tick appropriate box or complete details below)
Reaction/Type/Date
Reaction/e
Initials
MALE
D.O.B. _______ / _______ / _______
GIVEN NAME
FEMALE
Facility:
M.O.
ADDRESS
First Prescriber to Print Patient Pain specialist referral
Name and Check Label Correct: Referring doctor name: .........................
...................................................... Signature: ................................................
Date: ........................................................
Prescription is valid for a maximum of 7 days unless ceased earlier.
Refer to local hospital policy for standardised Ketamine solutions
Observations for this patient to be recorded:
2 hourly OR
Drug (print ‘ketamine’)
Amount (mg)
Diluent
(mg per mL)
FROM: …..mg per hour = …..mL per hour TO: …..mg per hour = …..mL per hour
Prescriber’s signature
Print your name
Contact
Pharmacy
Amount (mg)
Diluent
Total Volume (mL) Concentration
Sodium chloride 0.9%
Infusion start rate
Infusion range (if applicable)
…...mg per hour = ……mL per hour
Date
(mg per mL)
FROM: …..mg per hour = …..mL per hour TO: …..mg per hour = …..mL per hour
Prescriber’s signature
Print your name
Contact
Pharmacy
Revised prescription is valid until this chart is completed unless ceased earlier
Route
Drug (print ‘ketamine’)
Amount (mg)
Diluent
ADDRESS
LOCATION
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
{
Assess pain both at rest and with relevant movement. Document “R” for rest and “M” for movement
10
Severe pain
9
8
7
6
Moderate pain
5
4
3
Mild pain
2
1
No pain
0
{
{
10
9
8
7
6
5
4
3
2
1
0
Yes
Yes
No
No
mg or mL per hour (circle one)
Cumulative dose
mg or mL (circle one)
Two initials for change of ketamine
program
Ketamine program checked (initial)
once per shift, on patient transfer and
on change of bag or syringe
Subcutaneous or IV cannula site
secure, no signs of inflammation
(check 8 hourly)
COMMENTS
(mg per mL)
Infusion range (if applicable)
…...mg per hour = ……mL per hour
Date
M.O.
INFUSION RATE
Total Volume (mL) Concentration
Sodium chloride 0.9%
Infusion start rate
Holes Punched as per AS2828.1: 2012
Drug (print ‘ketamine’)
FEMALE
TIME
Dysphoric adverse effects present
BINDING MARGIN - NO WRITING
Revised prescription is valid until this chart is completed unless ceased earlier
Route
If PCA in
use,
document
pain
scores
on PCA
chart only
BINDING MARGIN - NO WRITING
Date
PAIN SCORE
Infusion range (if applicable)
…...mg per hour = ……mL per hour
MALE
DATE
Total Volume (mL) Concentration
Sodium chloride 0.9%
Infusion start rate
ALL OBSERVATIONS MUST BE GRAPHED
4 hourly.
Holes Punched as per AS2828.1: 2012
Route
Altered Calling Criteria
SMR130028
Ketamine Infusion (Adult)
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
D.O.B. _______ / _______ / _______
KETAMINE INFUSION (ADULT)
¶SMRÊ-Î<6Ä
LOCATION / WARD
Sign..............................Print..............................Date................
MRN
FAMILY NAME
MRN
FROM: …..mg per hour = …..mL per hour TO: …..mg per hour = …..mL per hour
Prescriber’s signature
Print your name
Contact
Pharmacy
Revised prescription is valid until this chart is completed unless ceased earlier
Amount (mg)
Diluent
Total Volume (mL) Concentration
Sodium chloride 0.9%
Infusion start rate
Infusion range (if applicable)
…...mg per hour = ……mL per hour
Date
(mg per mL)
FROM: …..mg per hour = …..mL per hour TO: …..mg per hour = …..mL per hour
Prescriber’s signature
Print your name
Contact
Pharmacy
¶SMRÊ-Î<6Ä
Drug (print ‘ketamine’)
SMR130028
Route
CEASE KETAMINE ACCORDING TO INSTRUCTIONS IN THE MEDICAL RECORD
Refer to entry in the medical record written on
Page 2 of 8
INITIAL:
Date:…............…. Time:......……
NO WRITING
NO WRITING
Page 7 of 8
MRN
FAMILY NAME
GIVEN NAME
D.O.B. _______ / _______ / _______
ALL OBSERVATIONS MUST BE GRAPHED
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
PAIN SCORE
If PCA in
use,
document
pain
scores
on PCA
chart only
TIME
{
Assess pain both at rest and with relevant movement. Document “R” for rest and “M” for movement
10
Severe pain
9
8
7
6
Moderate pain
5
4
3
Mild pain
2
1
No pain
0
{
{
Dysphoric adverse effects present
10
9
8
7
6
5
4
3
2
1
0
Yes
Yes
No
No
Cumulative dose
mg or mL (circle one)
Two initials for change of ketamine
program
Ketamine program checked (initial)
once per shift, on patient transfer and
on change of bag or syringe
Subcutaneous or IV cannula site
secure, no signs of inflammation
(check 8 hourly)
LOCATION / WARD
Record of ketamine administration and ketamine discarded
Record of ketamine
administration
Time
Record of ketamine
discarded
Signature Signature
1
2
Date
Time
Total ketamine
discarded
(mL or mg)
Signature
1
Signature
2
1
2
3
4
Holes Punched as per AS2828.1: 2012
mg or mL per hour (circle one)
M.O.
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Date
BINDING MARGIN - NO WRITING
INFUSION RATE
KETAMINE INFUSION (ADULT)
SMR130028
DATE
FEMALE
ADDRESS
ADDRESS
LOCATION
MALE
D.O.B. _______ / _______ / _______
Facility:
¶SMRÊ-Î<6Ä
Altered Calling Criteria
M.O.
BINDING MARGIN - NO WRITING
KETAMINE INFUSION (ADULT)
MRN
GIVEN NAME
FEMALE
Holes Punched as per AS2828.1: 2012
Facility:
MALE
FAMILY NAME
5
6
7
8
9
10
11
COMMENTS
12
13
14
¶SMRÊ-Î<6Ä
SMR130028
INITIAL:
Page 6 of 8
NO WRITING
NO WRITING
Page 3 of 8
MRN
FAMILY NAME
GIVEN NAME
D.O.B. _______ / _______ / _______
ALL OBSERVATIONS MUST BE GRAPHED
ADDRESS
LOCATION
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
PAIN SCORE
If PCA in
use,
document
pain
scores
on PCA
chart only
TIME
{
Assess pain both at rest and with relevant movement. Document “R” for rest and “M” for movement
10
Severe pain
9
8
7
6
Moderate pain
5
4
3
Mild pain
2
1
No pain
0
{
{
Dysphoric adverse effects present
10
9
8
7
6
5
4
3
2
1
0
Yes
Yes
No
No
Cumulative dose
mg or mL (circle one)
Two initials for change of ketamine
program
Ketamine program checked (initial)
once per shift, on patient transfer and
on change of bag or syringe
Subcutaneous or IV cannula site
secure, no signs of inflammation
(check 8 hourly)
Holes Punched as per AS2828.1: 2012
mg or mL per hour (circle one)
ALL OBSERVATIONS MUST BE GRAPHED
MALE
FEMALE
M.O.
ADDRESS
LOCATION
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
DATE
PAIN SCORE
If PCA in
use,
document
pain
scores
on PCA
chart only
TIME
{
Assess pain both at rest and with relevant movement. Document “R” for rest and “M” for movement
10
Severe pain
9
8
7
6
Moderate pain
5
4
3
Mild pain
2
1
No pain
0
{
{
Dysphoric adverse effects present
BINDING MARGIN - NO WRITING
INFUSION RATE
Altered Calling Criteria
SMR130028
DATE
D.O.B. _______ / _______ / _______
KETAMINE INFUSION (ADULT)
¶SMRÊ-Î<6Ä
Altered Calling Criteria
Facility:
M.O.
BINDING MARGIN - NO WRITING
KETAMINE INFUSION (ADULT)
GIVEN NAME
FEMALE
Holes Punched as per AS2828.1: 2012
Facility:
MALE
MRN
FAMILY NAME
10
9
8
7
6
5
4
3
2
1
0
Yes
Yes
No
No
INFUSION RATE
mg or mL per hour (circle one)
Cumulative dose
mg or mL (circle one)
Two initials for change of ketamine
program
Ketamine program checked (initial)
once per shift, on patient transfer and
on change of bag or syringe
Subcutaneous or IV cannula site
secure, no signs of inflammation
(check 8 hourly)
COMMENTS
COMMENTS
¶SMRÊ-Î<6Ä
SMR130028
INITIAL:
Page 4 of 8
INITIAL:
NO WRITING
NO WRITING
Page 5 of 8