VGH / UBCH / GFS /
PHYSICIAN’S ORDERS
/ADDRESSOGRAPH
RECONSTRUCTIVE ORTHOPAEDIC MULTIMODAL PAIN MANAGEMENT ORDERS
Page 1 of 3
Date: ______Time: ______
This order set is NOT intended for patients who have: severe chronic pain and or opioid tolerance, extensive revision, severe co-morbidity, or are over 80 years of age.
Intra-operatively patient received: q an intrathecal injection of ______Time:______
· Follow intrathecal monitoring on page 2 of 3
· Maintain IV access (IV or saline lock) for 24 hours after intrathecal injection
q wound infiltrate with local anaesthetic
Regular Analgesics
· acetaminophen 975 mg PO or 650 mg PR Q6H
o celecoxib 200 mg PO daily X 5 days. Start day 1 post-op (contra-indicated if allergic to sulpha, NSAID or
ASA and or heart disease or renal insufficiency)
OR
o diclofenac 50 mg PO/PR Q12H.
If able to tolerate oral medication
· Start long acting medication at 1800
· Give breakthrough as needed
o oxycodone Controlled Release 10 mg PO Q12H (for patients less than 60 kg or opioid sensitive)After 18 hours may increase dose to 20 mg PO if necessary. Inform pharmacy if dose increased.
o oxycodone Controlled Release 20 mg PO Q12H
After 18 hours may increase dose to 30 mg PO if necessary. Inform pharmacy if dose increased.
Oral Breakthrough Analgesics - Use if pain uncontrolled.
o oxycodone 5 mg to 10 mg PO Q4H PRN (for patients less than 60 kg or opioid sensitive)o oxycodone 10 mg to 20 mg PO Q4H PRN (for patients 60 kg or more) / o HYDROmorphone Controlled Release 3 mg Q12H PO (for patients less than 60 kg or opioid sensitive) After 18 hrs may increase dose to 6 mg PO if necessary. Inform pharmacy if dose increased.
o HYDROmorphone Controlled Release 6 mg PO Q12H. After 18 hours may increase dose to 9 mg PO if necessary. Inform pharmacy if dose increased.
Oral Breakthrough Analgesics - Use if pain uncontrolled.
o HYDROmorphone 1-2 mg PO Q4H PRN (for patients less than 60 kg or opiod sensitive)o HYDROmorphone 1-4 mg PO Q4H PRN (for patients 60 kg or more)
If IV breakthrough required when on oral, subcutaneous, or PCA routes:
o morphine 1-2 mg IV Q 10 MIN to a maximum of 5 mg in one hour.
OR
o HYDROmorphone 0.1- 0.2 mg IV Q10 MIN to a maximum of 0.5 mg in one hour
OR
o HYDROmorphone 0.1- 0.4 mg IV Q10 MIN to a maximum of 1 mg in one hour
159______/ ______
Physician Signature
ROMPMO / Printed Name/PIC
Rev. May-06
VGH / UBCH / GFS /
PHYSICIAN’S ORDERS
/ADDRESSOGRAPH
RECONSTRUCTIVE ORTHOPAEDIC PAIN MANAGEMENT ORDERS
______/ ______Physician Signature
ROMPMO / Printed Name/PIC
Rev. May-06
159
Page 2 of 3
Date: ______Time: ______
If unable to tolerate oral medication:
o morphine 5-10 mg subcutaneous Q4H PRN
OR
o morphine 10-20 mg subcutaneous Q4H PRN
OR
o HYDROmorphone 1-2 mg subcutaneous Q4H PRN
· Consult physician for inadequate pain control after maximizing interventions
MONITORING:
· If intrathecal morphine given, assess Respiratory Rate and Sedation Scale Q1H X 24 hours
· If no intrathecal dose given, assess Respiratory Rate and Sedation Scale Q1H X 2 hours, then Q4H x 24h,
then routine post-op monitoring
· Assess pain intensity Q1H until controlled, then Q4H
· Assess Respiratory Rate, Sedation Scale and pain intensity Q15 MIN x 2 following IV breakthrough
TREATMENT OF ADVERSE EFFECTS
· Over sedation/respiratory depression – SS greater than 2 and/or RR less than 8/min
· naloxone 0.1mg IV push Q 2MIN X 4 PRN until patient awakes
· Oxygen by face mask – 10 L/min
· NOTIFY PHYSICIAN STAT
· Reassess RR and SS q30minutes x 2 hours following last dose of naloxone then Q1H x 10 hours
Symptomatic Pruritis
o diphenhydrAMINE 25 mg PO/IV Q4H PRN (monitor Respiratory Rate & Sedation Scale Q15 MIN x 30
MIN until stable)
NAUSEA AND VOMITING
· Give the following in order listed in 30-minute intervals until control of nausea/vomiting
· If agent used is effective, continue with that agent at specified dose and frequency
· If treatment failure occurs change medications; if unresponsive to all medications page physician
o dolasetron 12.5 mg IV if effective, may repeat 12.5 mg IV Q12H PRN
o metoclopramide 10-20 mg IV if effective, may repeat 10-20 mg IV Q6H PRN
o prochlorperazine 5-10 mg IV if effective, may repeat 5-10 mg IV Q4H PRN
o dimenhyDRINATE 25-50 mg IV if effective, may repeat 25-50 mg IV Q4H PRN
HS Sedation: After 24 hours post-op:
o zopiclone 3.75 mg PO QHS PRN (repeat X 1 PRN)
o oxazepam 15 mg PO QHS PRN (repeat X 1 PRN)
o lorazepam 1 mg SL QHS PRN (repeat X 1 PRN)
Other: ______
VGH / UBCH / GFS /
PHYSICIAN’S ORDERS
/ADDRESSOGRAPH
RECONSTRUCTIVE ORTHOPAEDIC PAIN MANAGEMENT ORDERS
Page 3 of 3
Date: ______Time: ______
PCA Orders
PCA PRN for 1st 18 hours after intrathecal opioid injection
PCA MODE:· Incremental (PCA) Dose:
· Lockout Time:
· 4 hr Dose Limit: / o morphine (5 mg/mL) / o HYDROmorphone (1 mg/mL)
Start at:
______mg
______min
______mg / Range:
______mg
______min
______mg / Suggested
(0.5-1 mg)
(15-20 min)
(10 mg) / Start at:
______mg
______min
______mg / Range:
______mg
______min
______mg / Suggested
(0.1 mg)
(15-20 min)
(1-2 mg)
PCA PRN AFTER 1st 18 hour period or without intrathecal opioid injection
PCA MODE:· Incremental (PCA) Dose:
· Lockout Time:
· 4hr Dose Limit: / o morphine (5 mg/ml) / o HYDROmorphone (1 mg/mL)
Start at:
______mg
______min
______mg / Range:
______mg
______min
______mg / Suggested
(1-2 mg)
(6-12 min)
(30 mg) / Start at:
______mg
______min
______mg / Range:
______mg
______min
______mg / Suggested
(0.1-0.4mg)
(6-12 min)
(4-6 mg)
MONITORING:
· If intrathecal morphine given, assess Respiratory Rate (RR) and Sedation Scale (SS) q1h X 24 hours, then
Q4H
· If no intrathecal dose given, assess RR and SS Q1H X 2 hours, then Q4H
· Assess pain intensity q1h until controlled, then Q4H
· If pain control inadequate after maximizing interventions – page physician
· Assess RR, SS and pain intensity Q15MIN x 2 then Q1H x 2 following increase in incremental PCA dose and/or
decrease in patient lock out.
· Assess RR and SS Q1H X 2 following increase in 4 hour limit
TREATMENT OF ADVERSE EFFECTS (repeated from page 2 of 3 for nursing reference)
· Over sedation/respiratory depression – SS greater than 2 and/or RR less than 8/min
· naloxone 0.1mg IV push Q 2MIN X 4 PRN until patient awakes
· Oxygen by face mask – 10 L/min
· NOTIFY PHYSICIAN STAT
· Reassess RR and SS q30minutes x 2 hours following last dose of naloxone then Q1H x 10 hours
______/ ______Physician Signature
ROMPMO / Printed Name/PIC
Rev. May-06