Fentanyl - Patient Controlled Analgesia Order Form

Patient Stamp • Prior to start O2 supply and suction must be available • Must be Administered Via CareFusion / Alaris PCA Pump Module ONLY

Suggested FENTANYL PCA Dosing Regimen Physician Order for FENTANYL PCA Syringe (Fentanyl PCA 25 mL Syringe (10 Micrograms / mL))

1. PCA Dose: (Range: 5 - 20 MICROgrams) 1. PCA Dose: ______MICROgrams = ______mLs / Hr

2. Lock Out: (Range: 10 – 15 minutes) 2. Lock Out: ______Minutes

3. Basal Dose: (Continuous): (Range: 0 – 25 MICROgrams / Hr) 3. Basal Dose (Continuous): _____ MICROgrams / Hr

4. 1 Hour LIMIT: (Range: 25 – 125 MICROgrams / Hr) 4. 1 Hour LIMIT: ______MICROgrams / Hr = ______mLs / Hr

5. PCA Bolus Dose* : (Range: 10 – 20 MICROgrams) 5. PCA Bolus Dose* : ______MICROgrams Q ___Hr(s) PRN PRN Breakthrough Pain. Breakthrough Pain.

6. Loading Dose: (Range 10 – 25 MICROgrams 6. Loading Dose______MICROgrams X ONE Dose * Included in One Hour Limit. * Included in One Hour Limit.

MONITORING  Assess Respiratory Rate Q 10 minutes after initial dose for first hour then every hour x 6 hrs, then every 2 hours.  Continuous Pulse Oximetry. Notify MD for SPO2 < 90%  Pain Intensity (Document per scale)  Level of sedation (Document per scale)

NOTIFY PHYSICIAN for the following: (Must fill in all monitoring parameters) 1. For Respiratory Rate 10 per minute or less: a. STOP THE PCA b. START Nasal Oxygen at ______liters per minute c. ADMINISTER Naloxone 0.1 mg IV every 5 minutes x 4 doses PRN until Respiratory Rate is > 10 per minute and call M.D. 2. If Pulse below ______, or blood pressure below ______/ ______STOP PCA and notify M.D. 3. Severe pain; insufficiently controlled with current PCA settings.

SIDE EFFECTS MANAGEMENT: (Check boxes to initiate desired options) Nausea:  Ondansetron 4 mg IV Q 4 Hours PRN Nausea:  Ondansetron 4 mg PO Q 4 Hours PRN Nausea:  Other______Constipation:  Docusate sodium 100 mg PO BID PRN Constipation:  Senna (8.6 mg) 1 tablet PO BID PRN Constipation:  Other______

Clinical and Safety Practice Points • Evaluate all other opioid medications for discontinuation. • All boluses doses are to be administered via the CareFusion / Alaris PCA Pump • Use with caution in the elderly, in patients with renal or hepatic dysfunction or pulmonary disease; reduced dose may be indicated. • Use caution in craniotomy, head injury and increased ICP; respiratory depression may increase cerebral vasodilation and ICP. • May cause rigidity of respiratory muscles and may require muscle relaxant to permit artificial respiration. • Patients can appear to be asleep and may forget to breathe unless commanded to do so. • The following medications may increase fentanyl concentration thus potentiate sedation and decrease respiratory drive: Amiodarone, Calcium Channel Blockers, CNS Depressants, Droperidol, HIV Protease Inhibitors, Nefazodone, Azole Antifungals.

Physician Signature: ______Contact #______Date:______Time______

RN Signature: ______Date:______Time:______

Origin: 6/11; Revised: 12/12 *1268*