Whiteriver Indian Hospital

PCA Order Form

[Note: PCA Must be Reordered Daily]{.underline}

**1. Allergies:\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**2. Maintenance IV:\_\_\_\_\_\_\_\_\_\_\_\_\_\_at\_\_\_\_\_\_\_\_**per
hour (25ml/min min)

**3. Medication: (circle one)** Morphine 1mg/ml (Standard) Morphine
5mg/ml

Other:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4.  **Parameters:**

**Mode: (circle one)** PCA Continuous (Basal) PCA & Continuous (Basal)

####### 

#######  PCA Dose: \_\_\_\_\_\_MG Delay: \_\_\_\_\_MIN 

####### 

#######  Basal Rate: (circle one) No Yes: \_\_\_\_\_\_\_\_\_\_\_MG/HOUR 

##### 

##### 1 HOUR LIMIT \_\_\_\_\_\_MG/HOUR (must include basal rate if applicable)

# 

# BOLUS (Loading Dose): No Yes: \_\_\_\_\_\_\_\_\_\_MG AT\_\_\_\_\_\_\_\_\_\_

**[DOSING GUIDELINES]{.underline}**

*[Morphine]{.underline}*

Bolus Dose: 2mg-4mg

PCA Dose: 1mg-3mg

Lockout Interval: 10-15 minutes

Continuous infusion: 0-2mg/hr

> One Hour Limit: 4mg-8mg

5.  Nalaxone 0.4mg/ml and 3cc syringe to be available at all times.

6.  No systemic narcotics may be administered to patient by any provider
    while on PCA (except during taper).

7.  Diphenhydramine \_\_\_\_\_\_\_\_\_mg IV/IM/PO q \_\_\_\_ hours prn
    pruritus, nausea or vomitting.

MD SIGNATURE
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
. Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Time:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8/04 WRSU 10R

8/04 WRSU 10R

# [Note: PCA Must be Reordered Daily]{.underline}

# Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# Set Up & Order Verification by: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_RN/\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_RN

**Nalaxone available**: \_\_\_\_\_\_\_\_\_\_RN

Patient Education: [Initials]{.underline} [Date]{.underline}
[Initials]{.underline} [Date]{.underline}

Purpose of PCA \_\_\_\_\_\_ \_\_\_\_\_ Discussed Safety from Overdosing
\_\_\_\_\_\_\_ \_\_\_\_\_

Review of Pain Scale \_\_\_\_\_\_ \_\_\_\_\_ Discussed When to Call the
Nurse \_\_\_\_\_\_\_ \_\_\_\_\_

Review Button Use \_\_\_\_\_\_ \_\_\_\_\_

## 

## Starting Syringe Volume[:]{.underline} \_\_\_\_\_\_\_\_\_\_\_\_ Ending Volume Wasted:\_\_\_\_\_\_; \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_RN/\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_RN

<table>
<colgroup>
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 11%" />
<col style="width: 14%" />
<col style="width: 16%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>Date</strong></td>
<td><strong>Time</strong></td>
<td><h2 id="pain-scale">Pain Scale</h2></td>
<td><strong>BP</strong></td>
<td><strong>HR</strong></td>
<td><strong>RR</strong></td>
<td><strong>Sedation Level / LOC</strong></td>
<td><h3 id="side-effects">Side Effects</h3></td>
<td><h3 id="total-mgs-infused-per-shift">Total mgs Infused per
shift</h3></td>
<td><strong>Amount (mls) Left in Syringe @ end of shift</strong></td>
<td><p><strong>RN/RN*</strong></p>
<p><strong>Initials</strong></p></td>
</tr>
<tr class="even">
<td></td>
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</tbody>
</table>

**\* End of shift -- Two RNs must sign**

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  Signature                               Title             Initials

                                                            

                                                            

                                                            

                                                            

                                                            
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