Wording on the form has
been modified to coincide
254 Easton Ave., P.O. Box 591, New Brunswick, NJ 08903-0591 the new PCA
with that in Fentanyl has been added
pumps. For example:
to the order form
“Continuous” replaced the
PATIENT CONTROLLED ANALGESIA (PCA)
ORDER SHEET word “Basal”
Telephone Order: Write Down, Read Back provided to confirm order accuracy PATIENT LABEL
USE BALL POINT PEN ONLY
For children under age 13 specify weight: _____________ kilograms (Not recommended for children under five years of age)
Infusion type-check one:
PCA without infusion Continuous infusion with PCA Continuous infusion without PCA
DRUG MORPHINE DILAUDID FENTANYL (ICU only)
(Hydromorphone)
__________1mg/ml __________0.2mg/ml ________10 mcg/ml
Drug Concentration
__________5 mg/ml __________1 mg/ml ________50 mcg/ml
__________5 mg/ml
_____None _____None _____None
Loading Dose
_____2 mg _____0.3 mg _____25 mcg
_____3 mg _____0.4 mg _____50 mcg
_____4 mg _____0.6 mg _____other_________mcg
_____5 mg _____0.7 mg
_____other _________mg _____other________mg
_____None _____None _____None
PCA Dose
_____1mg _____0.2mg _____15 mcg
_____other_________mg _____other_________mg _____other_________mcg
_____10 minutes _____10 minutes _____10 minutes
Lockout
_____15minutes _____15minutes _____15minutes
_____20 minutes _____20 minutes _____20 minutes
_____other_________min. _____other_________min. _____other_________min
_____None _____None _____None
Continuous Rate (per hour)
_____0.5 mg _____0.1 mg _____25 mcg
_____1 mg _____0.2mg _____50 mcg
_____other_________mg _____other_________mg _____other________mcg
1 hour drug limit
________mg total per hour ________mg total per hour ______mcg total per hour
Increase Demand Dose Increase Demand Dose Increase Demand Dose
*For pain level
to:________mg. to:________mg. to:________mg.
greater than or equal to 5:
Decrease Lockout Decrease Lockout Decrease Lockout
*For pain level
to:________minutesa wider
Added
to:________minutes to:________minutes
greater than or equal to 5:
range of doses for
*If no improvement with these changes, notify MD
each agent for
KVO Solution of at ml/hr. Use main IV fluids
Primary IV: accuracy of dose
For respiratory distress, apnea or Sedation Scale of 4 (somnolent): Stop PCA.
& convenience
For adults and children weighing greater than 40kg, dilute 0.4 mg of Naloxone in 9 mL of Sterile Normal saline and administer 1 mL by IV
push every 1 minute until after alert or increase in respiratory rate greater than 12. Notify prescriber immediately. For respiratory depression
in children less than 40kg, Naloxone 0.01 mg/kg. IV push every 1 minute until alert or increase in respiratory rate. Notify prescriber
immediately.
Monitoring Parameters
On initiation of PCA, or administration of loading dose, monitor vital signs, sedation scale and pain levels every 15 minutes x 2, then every
2 hours x 2, then every 4 hours.
If the respiratory rate is less than 10, heart rate less than 50, or BP less than 90/50 in adults or in children 5-15 yrs., the respiratory rate is
less than 16, heart rate less than 80, BP less than 90/50, stop PCA and call prescriber.
Licensed Physician/Permit Holder ID # DATE TIME
Registered Resident Physician ID # DATE TIME
Allied Health Professional DATE TIME
Order Noted: RN DATE TIME