PATIENT CONTROLLED ANALGESIA (PCA) FLOW SHEET



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 |

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

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