Pharmacy & Therapeutics- July 2008 - (Page 423) Pain Management and Medication Errors The Hospital of Central Connecticut ADULT ACUTE PAIN IV Medication Orders PARENTERAL IV OPIOID: For patients who are unable to take oral opioids. NURSING INSTRUCTIONS: Administration: Use the Checked Table and Opioid Initial Test Dose: FIRST IV opioid dose: give the reduced dose per pain score. Assess patient at 15-30 minutes and if unsatisfactory relief (pain score > 4), may repeat initial reduced dose x one. Standard dose: If the last dose of IV opioid was given 2 or more hours ago, administer standard dose. Reduced dose: If the last dose of IV opioid (standard or reduced dose) was given ½ - 2 hrs ago, administer reduced dose for pain score > 4. Patient is NOT eligible for a standard dose until at least 2 hours have elapsed since last dose. Utilize all assessment parameters to verify patient’s reported pain score truly reflects the severity level: notify MD/PA for specific order if discrepancy exits. MAXIMUM 3 doses total (either standard or reduced) in 4 hours. DISCONTINUE IV OPIOID when ORAL begun CALL MD/PA/APRN IF: Patient has received the maximum of 3 doses in any 4 hour period without satisfactory relief. 2. Patient has altered level of alertness, DO NOT ADMINISTER OPIOID: “C or D” (C=Confused/impaired or arousable only with stimulation; D=Disoriented) 3. Patient has a respiratory rate less than 8/min. 4. Consider Rapid Response or Dr. Quick for # 2 or 3. MD/PA/APRN INSTRUCTIONS & ORDERS: 1. Patient Category (Select One and Check Table below): Category 1: Elderly / Frail, Opioid Naive Adult, or Renal Impairment Category 2: Standard Adult, Major Surgery / Injury Category 3: Opioid Tolerant Adult or if Category 2 ineffective * Warning: If pt is on any medication which is known to produce CNS depression, (i.e. benzodiazepenes, tricyclic antidepressants, phenothiazines: Phenergan® or Compazine®): use lower Category Opioid (Select One and Check Table below): Morphine Sulfate: Patients with normal renal function Hydromorphone (Dilaudid®): Indicated in patients with renal insufficiency/failure or intolerance to Morphine 2. 1. If patient consistently requires 3 doses in any 4 hour period without satisfactory relief: Evaluate patient: thorough assessment Consider Peripheral PCA Consider Pain Consult Select the following orders by checking box: Continuous pulse oximetry (High risk pts: obesity, sleep apnea, COPD, frail) Metoclopramide (Reglan®) 10 mg IV q 6 hrs PRN nausea Ondansetron (Zofran®) 4 mg IV q 6 hrs PRN refractory nausea Ketorolac (Toradol®) mg (15mg or 30mg) IV q 6 hours ATC x 3 days. (15 mg dose in pts >65 yrs, < 50 kg weight) Discontinue if oral NSAID begun. Omit in patients w/ renal insufficiency/failure, PUD/UGI bleed, anticoagulation/coagulopathy, thrombocytopenia, severe asthma. For Acute Severe Respiratory Depression, call RRT/Dr.Quick Naloxone (Narcan®) IVP 0.4 mg diluted in 10 ml NS slow IVP x one PRN acute severe respiratory depression CATEGORY 1: ELDERLY/FRAIL, OPIOID NAIVE ADULT, or Renal Impairment (Hydromorphone for Renal Impairment) PAIN SCORE Morphine Sulfate Hydromorphone (Dilaudid®) standard dose reduced dose standard dose reduced dose (2 or more hrs (½ - 2 hrs (2 or more hrs (½ - 2 hrs since last dose) since last dose) since last dose) since last dose) 1 – 3 mild 1 mg IV 0.5 mg IV 0.2 mg IV 0.1 mg IV 4 – 7 moderate 2 mg IV 1 mg IV 0.4 mg IV 0.2 mg IV 8 – 10 severe 4 mg IV 2 mg IV 0.6 mg IV 0.3 mg IV CATEGORY 2: STANDARD ADULT, Major Surgery / Injury PAIN SCORE Morphine Sulfate standard dose reduced dose (2 or more hrs (½ - 2 hrs since last dose) since last dose) 1– 3 mild 2 mg IV 1 mg IV 4 – 7 moderate 5 mg IV 2 mg IV 8 – 10 severe 8 mg IV 4 mg IV Hydromorphone standard dose (2 or more hrs since last dose) 0.4 mg IV 0.8 mg IV 1.2 mg IV (Dilaudid®) reduced dose (½ - 2 hrs since last dose) 0.2 mg IV 0.4 mg IV 0.6 mg IV CATEGORY 3: OPIOID TOLERANT ADULT or Category 2 ineffective (evaluate patient) PAIN SCORE Morphine Sulfate Hydromorphone (Dilaudid®) standard dose reduced dose standard dose reduced dose (2 or more hrs (½ - 2 hrs (2 or more hrs (½ - 2 hrs since last dose) since last dose) since last dose) since last dose) 1– 3 mild 4 mg IV 2 mg IV 0.6 mg IV 0.3 mg IV 4 – 7 moderate 8 mg IV 4 mg IV 1.2 mg IV 0.6 mg IV 8 – 10 severe 12 mg IV 6 mg IV 2 mg IV 1 mg IV HCC Form # 1595 Rev. 6/08 Signature / Print Name Date / Time ADULT ACUTE PAIN Parenteral IV Medication Orders Vol. 33 No. 7 • July 2008 • P&T® 423
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