Unique Plan Description: PCA Titratable Hydromorphone (Dilaudid)
Plan Selection Display: PCA Titratable Hydromorphone (Dilaudid)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2100-12-31 00:00:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2026-04-13 17:38:15
Available at all facilities: No

PCA Titratable Hydromorphone (Dilaudid)
IV Solutions
	Sodium Chloride 0.9%
		500 mL, IV, 20 ml/hr
			Comment: If no current IV fluid order.
Medications
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	Dilaudid Injectable
		0.5 mg, Injection, IV Push, Once, PRN see comment, Routine, duration: 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
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	HYDROmorphone 0.2 mg/mL PCA 50mL Standard IV
		Continuous Dose (mg/hr) 0 - 0.2, Patient Admin Bolus (mg) 0.1 - 0.2, Lockout Interval (min) = 10, 4-hour Limit (mg) 3, Nurse Admin Bolus (mg) 0.2, Nurse Admin Bolus Freq 1, 50 mL, PCA IV, PCA
			Comment: STANDARD W/BASALBASAL RATE:   Mild Pain (pain score 1-3)= No basal    Moderate Pain/Severe Pain (Pain Score 4-10) = Start at 0.1mg/hr    Titration = up/down 0.1mg/hr up to a maximum of 0.2mg/hr as needed for moderate or severe pain (pain score 4-10)    D/C basal rate = if dose required is less than 0.1mg/hr (side effects present) and use patient-controlled dosing only.PATIENT CONTROLLED DOSE:   Mild/Moderate Pain (pain score 1-6)= Start at 0.1mg   Severe Pain (pain score 7-10) = Start at 0.2mg   Titrate: Adjust by 0.1mg every 30 minutes up to a maximum of 0.2mg   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:   Respiratory rate is < or = 12 bpm and/or   RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  DO NOT RESUME PCA UNLESS:   RR > or = 12bpm and normal depth and RASS 0 to -1, alertRESUMING PCA AFTER STOP:   Consider oxygen protocol   Basal Rate = discontinue   Patient controlled dose = Restart at 0.1mgDISCONTINUE PCA & PROTOCAL AND Notify Provider 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.
		10 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
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	Dilaudid Injectable
		0.5 mg, Injection, IV Push, Once, PRN see comment, Routine, duration: 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
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	HYDROmorphone 0.2 mg/mL PCA 50mL Standard IV
		Continuous Dose (mg/hr) No basal rate, Patient Admin Bolus (mg) 0.1 - 0.2, Lockout Interval (min) = 10, 4-hour Limit (mg) 3, Nurse Admin Bolus (mg) 0.2, Nurse Admin Bolus Freq 1, 50 mL, PCA IV, PCA
			Comment: STANDARD-NO BASAL  Basal Rate = No basal PATIENT CONTROLLED DOSE:   Mild/Moderate Pain (pain score 1-6)= Start at 0.1mg   Severe Pain (pain score 7-10) = Start at 0.2mg   Titrate: Adjust by 0.1mg q30min up to a maximum of 0.3mg 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 HR IF:   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:   RR > or = 12bpm and normal depth   RASS 0 to -1, alertRESUMING PCA AFTER STOP:   Consider oxygen protocol   Basal Rate = discontinue   Patient controlled dose = Restart at 0.1mgDISCONTINUE PCA & PROTOCOL and Notify Provider 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.
		10 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
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	Dilaudid Injectable
		0.3 mg, Injection, IV Push, Once, PRN see comment, Routine, duration: 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
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	HYDROmorphone 0.2 mg/mL PCA 50mL Standard IV
		10 mg, EVERY BAG
		Continuous Dose (mg/hr) No basal rate, Patient Admin Bolus (mg) 0.1 - 0.2, Lockout Interval (min) = 15, 4-hour Limit (mg) 2, Nurse Admin Bolus (mg) 0.2, Nurse Admin Bolus Freq 1, 50 mL, PCA IV, PCA
			Comment: HIGH RISK PROTOCOLBasal Rate = No basal PATIENT CONTROLLED DOSE:   Mild/Moderate Pain (pain score 1-6)= Start at 0.1mg   Severe Pain (pain score 7-10) = Start at 0.2mg   Titrate:  Adjust by 0.1mg every 30 minutes up to a maximum of 0.2mg   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:   Respiratory rate is < or = 12 bpm and/or   RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  DO NOT RESUME PCA UNLESS:   RR > or = 12bpm and normal depth and RASS 0 to -1, alertRESUMING PCA AFTER STOP:   Consider oxygen protocol   Basal Rate = discontinue   Patient controlled dose = Restart at 0.1mgDISCONTINUE PCA & PROTOCOL AND Notify Provider 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.
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
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	Dilaudid Injectable
		1 mg, Injection, IV Push, Once, PRN see comment, Routine, duration: 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
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	HYDROmorphone 0.2 mg/mL PCA 50mL Standard IV
		Continuous Dose (mg/hr) 0.3 - 0.6, Patient Admin Bolus (mg) 0.1 - 0.5, Lockout Interval (min) = 10, 4-hour Limit (mg) 4, Nurse Admin Bolus (mg) 0.3, Nurse Admin Bolus Freq 1, 50 mL, PCA IV, PCA
			Comment: OPIATE TOLERANT PROTOCOLBASAL RATE:   Mild Pain (pain score 1-3)= 0.1mg/hr    Moderate Pain/Severe Pain (Pain Score 4-10) = Start at 0.3mg/hr    Titration = up/down 0.1mg/hr up to a maximum of 0.6mg/hr as needed for moderate or severe pain (pain score 4-10)    D/C basal rate = if dose required is less than 0.1mg/hr (side effects present) and use patient-controlled dosing only.PATIENT CONTROLLED DOSE:   Mild/Moderate Pain (pain score 1-6)= Start at 0.1mg   Severe Pain (pain score 7-10) = Start at 0.2mg   Titrate: Adjust by 0.1mg every 30 minutes up to a maximum of 0.5mg   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:   Respiratory rate is < or = 12 bpm and/or   RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  DO NOT RESUME PCA UNLESS:   RR > or = 12bpm and normal depth and RASS 0 to -1, alertRESUMING PCA AFTER STOP:   Consider oxygen protocol   Basal Rate = discontinue   Patient controlled dose = Restart at 0.2mgDISCONTINUE PCA & PROTOCOL AND Notify Provider 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.
		10 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
	Narcan
		0.1 mg, Injection, IV Push, Q5MIN, PRN see comment
			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 protocol.

PCA Titratable Patient Care Subphase
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. 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 </= 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: RT, while on PCA

PCA Titratable Patient Care Subphase
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. 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 </= 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: RT, while on PCA

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
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