PLACE LABEL HERE
PATIENT CONTROLLED ANALGESIA (PCA)
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
Drug
(concentration)
Use
Initial loading dose
PCA demand dose
PCA lockout interval
4 hour dose limit
Continuous rate
Supplemental bolus dose
PCA Medication:
Morphine
(1 mg/ml)
Dilaudid (HYDROmorphone)
(0.2 mg/ml)
Most patients;
Caution with poor renal function
1–2 mg
Patients unable to be managed with morphine
0.5–1 mg
1–2 mg
6–10 min
Usual 20 mg
Maximum 30 mg
0.5-2 mg/hr
1-2 mg
Maximum 5 doses in 4 hrs
 Morphine
0.2–0.4 mg
6–10 min
Usual 4 mg
Maximum 6 mg
0.1-0.5/hr
0.25-0.5 mg
Maximum 5 doses in 4 hrs
 Dilaudid (HYDROmorphone)
1.
2.
3.
4.
5.
6.
7.
 Initial loading dose (prior to starting PCA): _______________ mg IV x 1 dose
Mode of delivery:
 PCA only
 Continuous only
 PCA + continuous
PCA demand dose: _________________________________________ mg
PCA lockout interval: ________________________________________ min
Four hour dose limit: ________________________________________ mg
Continuous rate (if applicable): ________________________________ mg/hr
Supplemental IV bolus doses:
If Morphine PCA, give:
Morphine 1-2 mg IV (not PCA)
If Dilaudid (HYDROmorphone) PCA, give: HYDROmorphone 0.25-0.5 mg IV (not PCA)
Repeat q 15 min prn pain. Do not exceed 5 doses in 4 hrs
8.
Discontinue PCA :  in 12 hrs  in 24 hrs  POD 1 at 0600  POD 2 at 0600
 When ordered to do so by provider
OTHER MEDICATIONS
9.
IV fluids:  As per previous physician orders or  ______________ IV at ______ ml/hr for PCA line
10. If CNS or respiratory depression occurs (LOS Score = 4 and respiratory rate ≤ 8):
Narcan (naloxone) 0.4 mg diluted in NS 10 ml (0.04 mg/ml), administer 1 ml q 2 min until LOS Score = 2
and respiratory rate > 10, Notify physician
Sedation Scale:
0 - Awake, alert
1 - Occasionally drowsy, easy to arouse
2 - Frequently drowsy or normal sleep, easy to arouse
3 - Somnolent, difficult to arouse
4 - Obtunded, unable to arouse
________________ _______________
Date
Time
*1-2119*
1
_________________________________
Physician Signature
FORM 1-2119 REV. 05/2015
WHITE: Medical Record
___________
PID Number
CANARY: Pharmacy
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