<p> Gettysburg Hospital PCA Assessment Flow Sheet Date Medication Basal Rate Unit Dose Lockout Total per Hour</p><p>Document assessment Every 2 hours for patient with basal rate, Every 4 hours for all others with PCA.</p><p>Time 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 01 02 03 04 05 06 Pain Level Location mg/mcg given Attempts- q 8º Injections- q 8º Effective- Ineffective Resp. Rate Pulse-Ox LOC stage B/P Patient Instruction Visitor Instruction Initials Levels Of Consciousness Pain Scales Stage 1. Full alert wakefulness, normal speech and |____|____|____|____|____|____|____|____|____| behavior. Oriented to time, place and person. Stage 2. Hard to arouse but when aroused is oriented to ____| time and place. 0 1 2 3 4 5 6 7 8 9 Stage 3. Disoriented to time and place. May be hard to 10 arouse. Obeys simple verbal commands. Stage 4. Does not obey simple commands. Responds to pain by withdraw or grimacing-purposeful movements. Stage 5. Responds to pain with automatic purposeless reflex movements. Stage 6. Does not respond to pain.</p><p>Criteria for Initiation and Continuation of PCA in the Acute Pain Patient: 1. Respirations must be greater than 10. Respirations need to be assessed without arousing the patient. If respirations less than 10, stop PCA, obtain pulse ox, notify physician. If respirations are 8 or less implement Narcan protocol immediately. 2. Oriented- Patient must be oriented to purpose and function of PCA. If patient LOC progresses beyond stage 2, stop PCA, notify physician. 3. Blood Pressure- B/P must be greater than 100mm systolic. If patient baseline systolic less than 100mm, B/P must be within 20% of patient’s baseline. If patient’s B/P falls below criteria, stop PCA, notify physician. Initials Signature Initials Signature Location Description 1 Surgical Site 2 3 4 MR- pilot 4</p>