Unique Plan Description: PCA morphine
Plan Selection Display: PCA morphine
PlanType: Medical                                 
Version: 3          
Begin Effective Date: 2025-02-06 11:03:14
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-02-06 11:14:53
Available at all facilities: Yes

PCA morphine
IV Solutions
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	Sodium Chloride 0.9%
		500 mL, IV, 20 ml/hr
			Comment: If no current IV fluid order.
Medications
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	morphine  IV
		2 mg, Syringe, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	morphine 1 mg/mL PCA 50 mL IV
		Continuous Dose (mg/hr) 0 - 2 mg/hr, Patient Admin Bolus (mg) 0.5 - 1.5 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 30 mg, Nurse Admin Bolus (mg) 1 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 50 mL, PCA IV, PCA
			Comment: STANDARD W/BASAL. Adjust to patient's documented individual pain goal.   Begin with no basal for mild/moderate pain and begin with 1mg/hr severe pain; adjust dose up by 0.5mg/hr q30min to a maximum of 2mg/hr as needed for moderate or severe pain (pain score >3) and decrease by 0.5mg q30min as needed for mild to moderate pain.  DC basal rate if dose required is less than 0.5mg/hr (side effects present) and use patient controlled dosing only. Start Pt controlled dose at 1mg, increase by 0.5mg q30min up to a maximum of 1.5mg as needed for moderate or severe pain (pain score >3) and decrease by 0.5mg q30min as needed for mild to moderate pain. Dose adjustment of EITHER the continuous or patient administered dose may occur every 30 minutes, do not adjust both continuous or PCA dose at the same time (exception for comfort care patients) - Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, discontinue basal if running, and restart patient controlled dose at 0.5mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		50 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
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	morphine  IV
		2 mg, Syringe, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	morphine 1 mg/mL PCA 50 mL IV
		Continuous Dose (mg/hr) No basal dosing, Patient Admin Bolus (mg) 0.5 - 1.5 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 30 mg, Nurse Admin Bolus (mg) 1 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 50 mL, PCA IV, PCA
			Comment: STANDARD-NO BASAL. Adjust to patient's documented individual pain goal. No basal rate. Start Pt controlled dose at 0.5mg adjusting dose up by 0.5mg q30min to a maximum of 1.5mg as needed for mild to moderate pain and start at 1mg, adjusting dose up by 0.5mg q30min to a maximum of 1.5mg as needed for severe pain and down by 0.5mg q30min as needed for mild to moderate pain. -  Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, discontinue basal if running, and restart patient controlled dose at 0.5mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		50 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
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	morphine  IV
		1 mg, Syringe, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	morphine 1 mg/mL PCA 50 mL IV
		Continuous Dose (mg/hr) No basal dosing, Patient Admin Bolus (mg) 0.5-1.5 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 15 mg, Nurse Admin Bolus (mg) 1 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 50 mL, PCA IV, PCA
			Comment: HIGH RISK PROTOCOL. Adjust to patient's documented individual pain goal. No basal rate. Start Pt controlled dose at 0.5mg, adjust dose up by 0.2mg q30min to a maximum of 1.5mg for moderate to severe pain (pain score >3) and down by 0.2mg q30min as needed for mild to moderate. -  Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, discontinue basal if running, and restart patient controlled dose at 0.5mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order
		50 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		
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	morphine  IV
		4 mg, Syringe, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	morphine 1 mg/mL PCA 50 mL IV
		50 mg, EVERY BAG
		Continuous Dose (mg/hr) 1-4 mg/hr, Patient Admin Bolus (mg) 0.5-3 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 40 mg, Nurse Admin Bolus (mg) 2 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 50 mL, PCA IV, 1 mg/hr
			Comment: OPIATE TOLERANT PROTOCOL. Adjust to patient's documented individual pain goal. Begin with 2mg/hr and adjust dose by 0.5mg/hr q30min up to a maximum of 4mg/hr as needed for moderate to severe pain (pain score>3) and down by 0.5mg q30min as needed for mild to moderate pain. Start Pt controlled dose at 1.5mg, and increase dose by 0.5mg q30min up to a maximum of 3mg as needed for moderate to severe pain (pain score>3) and down by 0.5mg q30min as needed for mild to moderate pain. Dose adjustment of EITHER the continuous or patient administered dose may occur every 30 minutes, do not adjust both continuous or PCA dose at the same time (exception for comfort care patients) - Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, discontinue basal if running, and restart patient controlled dose at 1.5mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
	Narcan
		0.1 mg, Injection, IV Push, Q5MIN, PRN, see comment, Routine
			Comment: Until desired response.  Follow with 10 mL NaCl Flush, for patients who are somnolent with minimal or no response to stimuli, RASS -3 to -5, or for respiratory rate less than or equal to 10/minute, notify physician while on PCA.
Patient Care
	PCA Assessment
		T;N, Q15MIN, 4, Dose(s)/Time(s)
			Comment: Assessment to include vital signs, pain, RASS, resp rate, resp pattern, pump settings, and ETCO2 if appropriate.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N+60, Q1H, 4, Dose(s)/Time(s)
			Comment: Assessment to include vital signs, pain, RASS, resp rate, resp pattern, pump settings, and ETCO2 if appropriate. Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N+420, Q2H-Sch
			Comment: Assessment to include vital signs, pain, RASS, resp rate,resp pattern, pump settings, and ETCO2 if appropriate.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N
			Comment: ongoing, with any patient controlled dose, basal rate change or nurse administered bolus. Assessment to include vital signs, pain, RASS, resp rate, resp pattern and pump settings, and ETCO2 if appropriate. If resp rate <10, or SBP <90 reassess patient q15min x4, then q1h x4, then q2h.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
	Notify MD
		T;N, if respirations < or = 10, or  systolic BP < 90. PCA protocol.
		T;N, if patient is on Benzodiazepines (lorazepam, midazolam, diazepam etc). PCA protocol
		T;N, if pain increases or unable to wean in 12 hr
		T;N, if ETCO2 greater than 50
	PCA Parameters
		T;N
			Comment: Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR < or = 12bpm and normal depth, alert.  Consider oxygen protocol.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		T;N
			Comment: Do not initiate any PCA (continuous or patient administered doses) in patients with sleep apnea (OSA) without verbal verification from physician.  Basal (continuous) PCA dosing should not be used for patients with history of sleep apnea (OSA), or respiratory problems (lung disease, heart failure). Do not use patient controlled doses of PCA unless patient is fully able to understand and comply with instruction -this includes restricting use for patients with dementia, delirium, confusion. Start dosing at the lowest range possible for continuous and patient administered doses (exceptions comfort care patients, oncology patients routinely receiving opiates, chronic pain patient routinely receiving opiates), including starting with no basal rate.
	PCA weaning parameters
		T;N
			Comment: 1.  Administer oral opiate.2.  Provide patient education on weaning process3.  If a basal (continuous) rate is running, turn it off upon administration of oral opiate4.  Begin demand (patient controlled dose) wean 4hr after initial opiate dose.  Every 4hr decrease demand dose by 50% until adequate pain control is achieved (defined as a pain scale of <4 or meeting patient's goal for pain control).  Do not decrease demand below minimum dose in PCA protocol for patient controlled dosing (0.5mg morphine, 0.1mg hydromorphone)5.  If patient does not use demand dose in at least 4hr after receiving oral medication, discontinue PCA.6.  Notify MD if pain increases or unable to wean in 12hr.
Therapies
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
			Comment: while on PCA

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IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase