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PATIENT CONTROLLED ANALGESIA _PCA_ FLOW SHEET

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PATIENT CONTROLLED ANALGESIA _PCA_ FLOW SHEET Powered By Docstoc
					Gettysburg Hospital PCA Assessment Flow Sheet
 Date
 Medication
 Basal Rate
 Unit Dose
 Lockout
 Total per Hour

Document assessment Every 2 hours for patient with basal rate, Every 4 hours for all others with PCA.
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              0    1 2      3    4     5    6   7     8   9    10
time and place.
Stage 3. Disoriented to time and place. May be hard to
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.

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