CHN2617 Adult ICU Pain Orders.pdf - Carondelet

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USE BALL POINT PEN – PRESS FIRMLY
CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
ADULT ICU PAIN ORDERS
Physician Signature: Date Signed: Time Signed:
STAT/NOW
(Check Box to Left)
* LIST ALL ALLERGIES: (Medication, food, latex and/or Contrast Dye) * Required on Admission Orders
1. Titrate to target pain: (Mild pain unless otherwise stated by patient)
2. For patients pain select one of the following:
NO RANGE ORDERS ALLOWED
3. FentaNYL CONTINUOUS INFUSION:
FentaNYL infusion at ___________ microgram/hour IV (e.g., 25-50 microgram/hour)
• FentaNYL bolus at _________ microgram (e.g., 25 microgram) IV every 5 minutes p.r.n moderate pain
• FentaNYL bolus at _________ microgram (e.g., 50 microgram) IV every 5 minutes p.r.n severe pain
Repeat boluses until pain controlled
If the patient requires more than 2 boluses in an hour, increase rate by _______ microgram/hour IV (e.g., 12.5-25
microgram/hour) every hour
Maximum dosage = ________ microgram/hour IV (e.g., 100-200 microgram/hour)
Notify Physician if patient becomes hemodynamically unstable, for oversedation, or when pain control is not
achieved at maximum dosage
4. MORPHINE CONTINUOUS INFUSION (Avoid in patients with cardiovascular instability or renal impairment)
Morphine infusion at _________ mg/hour IV (e.g., 2 - 4 mg/hour)
• Morphine bolus at _________ mg (e.g., 2 mg) IV every 10 minutes p.r.n moderate pain
• Morphine bolus at _________ mg (e.g., 4 mg) IV every 10 minutes p.r.n severe pain
Repeat boluses until pain controlled
If the patient requires more than 2 boluses in an hour, increase rate by __________ mg/hour IV (e.g., 1-2 mg/hour)
every hour
Maximum dose = ________ mg/hour IV (e.g., 10 mg/hour IV)
Notify Physician if patient becomes hemodynamically unstable, for oversedation, or when pain control is not achieved
at maximum dosage
HYDROmorphone CONTINUOUS INFUSION
HYDROmorphone infusion at _________ mg/hour IV (e.g., 0.4-0.8 mg/hour)
• HYDROmorphone bolus at _________ mg (e.g., 0.4 mg) IV every 10 minutes p.r.n moderate pain
• HYDROmorphone bolus at _________ mg (e.g., 0.8 mg) IV every 10 minutes p.r.n severe pain
Repeat boluses until pain controlled
If the patient requires more than 2 boluses in an hour, increase rate by _______ mg/hour IV (e.g., 0.2-0.4 mg/hour)
every hour
Maximum dose = ________ mg/hour IV (e.g., 3 mg/hour IV)
Notify Physician if patient becomes hemodynamically unstable,, for oversedation, or when pain control is not achieved
at maximum dosage
Physician Printed Name / License # / Telephone #:
PATIENT IDENTIFICATION
MEC Approval CSJ – 06/30/11 CSM – 06/30/11 CHC – 06/23/11 CHVI – 06/22/11
CHN2617 Expires – 06/2014
Copy 05.02.13 Page 1 of 2
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

USE BALL POINT PEN – PRESS FIRMLY
CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
ADULT ICU PAIN ORDERS
STAT/NOW
(Check Box to Left)
Critical Care Pain Observation Tool (CPOT)
For non-communicative adults in critical care areas
0 1 2 Score
Facial Expression
Relaxed, neutral; no
muscular tension
observed
Tense; presence of
frowning, brow lowering,
orbit tightening, and
levator contraction
Grimacing; all facial
movements for 1 plus
eyelid tightly closed
Body Movement
Absence of movements;
does not move at all
(does not necessarily
mean absence of pain)
Protection; slow, cautious
movements; touching or
rubbing site; seeking
attention through
movement
Restlessness; pulling
tubes; attempting to sit
up or get out of bed;
moving limb/thrashing;
not following
commands; striking out
Ventilator Compliance
(intubated patients)
OR
Vocalization
Tolerating ventilator or
movement; alarms not
activated; easy
ventilation
Talking in normal tone or
no sound
Coughing but tolerating;
alarms stop spontaneously
Sighing; moaning
Fighting ventilator;
asynchrony; blocking
ventilation; alarms
frequently activated
Crying out; sobbing
(extubated patients)
Muscle Tension (evaluate
by passive UE flexion and
extension at rest or
evaluate when turning
patient)
Relaxed; no resistance
to passive movements
Tense, rigid; resistance to
passive movements
Very tense or rigid;
strong resistance to
passive movements;
inability to complete
them
Mild: 1-2 Moderate: 3-5 Severe: 6-8
Total:
(0-8)
Visual Analog Scale (Communicative Adults)
Wong-Baker (Non-Communicative Adults)
Physician Signature: Date Signed: Time Signed:
Physician Printed Name / License # / Telephone #:
PATIENT IDENTIFICATION
MEC Approval CSJ – 06/30/11 CSM – 06/30/11 CHC – 06/23/11 CHVI – 06/22/11
CHN2617 Expires – 06/2014
Copy 05.02.13 Page 2 of 2
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED