Standard of Nursing Practice:
Fox Chase Cancer Center
Fox Chase Cancer Center; Nursing Standards
Committee Pain Management Center Staff
FOX CHASE CANCER CENTER DEPARTMENT OF NURSING
STANDARD OF NURSING PRACTICE
PRACTICE AREA: OPIATE INFUSIONS
STANDARD: Nursing care of the patient receiving continuous
infusion of opiates for pain control will
maximize opiate effectiveness and minimize
potential for complications.
1. Nurses will monitor patients every ½ hour x 2 at initiation of therapy and then hourly until the individual achieves comfort and demonstrates stable status as indicated by absence of intolerable toxicity. Stable patients will be monitored every two hours.
2. Monitoring will include:
- medication identification
- confirmation of dosage
- observation of infusion site
- pre-assessment / response to therapy
- level of consciousness
- respiratory rate
- side effect profile
NB: It is not necessary to awaken stable patients during the night to assess pain and level of consciousness.
3. Pulse and BP will be monitored at the start of the infusion and then once each eight hour shift. Additional monitoring of vital signs is determined by the individual patients status, response to therapy, and treatment goals.
4. Spinal narcotics require hourly monitoring for 24 hours after initiation of therapy, bolus dose or change in dosage. Onset of respiratory depression may occur up to 24 hours after an opiate is infused due to drug redistribution.
5. Dosage changes will require restarting the monitoring process at q 1/2 hour.
6. Monitoring that reveals inadequate pain control or excessive toxicity will prompt nursing actions to alter the treatment.
1. Use equianalgesic charts to collaborate with physicians in identifying appropriate doses of analgesic for indivicual patients. Infusions are most effective when preceded by a loading dose of medication.
2. Nurses will calculate appropriate concentration of drug to fluid and collaborate with physician and pharmacist to keep volume of infused fluid appropriate for selected route and patient status.
The specific narcotic concentrations for infusion are:
- Morphine Sulfate 100mg/500ml D5W
- Morphine Sulfate 500mg/500ml D5W
- Hydromorphone 50mg/500ml D5W
- Hydromorphone 100mg/500ml D5W
- Hydromorphone 500mg/500ml D5W
3. Supplemental dose (rescue dose) orders will be obtained to treat breakthrough pain.
4. The intravenous infusion will be administered ONLY through a controlled system. NOTE: Narcotics added to I.V. fluid containers must, by law, be secured in a compartment with double locks until hung at the bedside. Thus, security and storage may influence the division of the full 24-hour dose to be given. Special delivery arrangements with the pharmacist may be needed to ensure sage storage of the narcotic fluids at all times.
5. The PCA pump will be "cleared" at the completion of the syringe.
6. When the pharmacy is closed (2300-0700), it will be the responsibility of the staff RN to mix the narcotic infusion. Provisions have been made to keep morphine and hydromorphone with infusion rate labels on 3 North with the floor narcotic disposition form. The pharmacist should be notified the next morning of any usage.
7. Opiate infusions, including PCAS, may hang longer than twenty-four hours. Upon discontinuation or removal of any narcotic infusion, the amount remaining should be recorded. The unused portion may be disposed of on the nursing station and should not be returned to the pharmacy. The amount remaining and its destruction shall be noted on the disposition from and initialed by two nurses. Discontinued narcotic infusions which have not been used (i.e., "unspiked") should be signed off the narcotic disposition record with a pharmacy staff members signature and the infusion then returned to pharmacy.
8. The rate of administration will be determined on a daily basis with mandatory twenty-four hour, complete rewrites by the physician. Orders written as "continue with same", "same as previously", or "renew MSO4 and drip" are unacceptable as an order.
9. Refer to "Analgesic Flow Sheet" in Documentation Manual for nursing documentation.
Side Effect Intervention
Anticipate side effects associated with therapy and implement preventive measures.
CNS Respiratory depression UNEXPECTED decrease in volume and rate of respiration, usually < 8 min. will be treated by reducing the infusion by 25%, stimulating the patient, and notifying the house physician. Narcan should be avoided if at all possible due to the potential sympathetic crisis and/or exacerbation of the patients pain subsquent to its administration. Titration of the intravenous narcotic dose should by done in a gradual and step-wise manner to prevent excessive depression of the respiratory rate. Excessive dosage is best controlled by slowing or stopping the infusing rate and allowing the drug level to fall on its own, if at all possible.
Myoclonus and seizures occur most often with chronic high dose administration. Benzodiazepines can be beneficial. Mental status changes sedation, confusion and agitation require provision of safe environment.
GI Nausea/vomiting will be reported, etiologly pursued and preventative antiemetics utilized.
Constipation will be prevented by monitoring bowel function each day and laxatives utilized to maintain regular stools q 72 hours.
Dry mouth will be treated with mouth care q 1-2 hours.
RENAL Clinically significant urinary hesitancy and retention occurs infrequently, and usually in men. Intermittent catheterization may be necessary for a short time.
OTHER Pruritus - rare side effect treated with antihistamines or very low dose Narcan.
1. Ensure consistent, systematic communication regarding patient response to treatment.
2. Flow sheets are used to determine safety and effectiveness of treatment.
3. Total volume of narcotic infused and number of supplements or bolus doses utilized will be transcribed with other monitoring data (not less than every two hours).
1. Patient and family will be assessed for level of understanding of therapy. Instructions/teaching will be offered as indicated.
2. Nurses will collaborate on discharge plans and instructions regarding site care and pump technology prior to discharge and followed up at home by Home Care Agency as indicated.
3. Prior to discharge the patient and/or caregiver are taught to demonstrate turning the pump on and off, replacing the battery and administering rescue dose. Additional activities of changing the delivery bag or cassette and changing the infusion site may be taught as time allows and patient/significant other are able.
4. Provide emergency access to healthcare provider for trouble shooting after discharge.
NOTE: Hospitalized individuals are considered to need more monitoring and care than can be provided in other settings. Increased monitoring is indicated for individuals who have been previously stabilized on opiate infusions in the outpatient setting. Unusual situations can be reviewed and alterations in policy made to accommodate patient goals.
McCaffery, M. and Beebe, A. Pain: A Clinical Manual for Nursing 1989. Mosby, St. Louis., pp. 93-115.
Spross, J., McGuire, D., Schmitt, R. Oncology Nursing Society Position Paper on Cancer Pain, Part I ONF 17 (4): 595-614, 1990.
Spross, J., McGuire, D., Schmitt, R. Oncology Nursing Society Position Paper on Cancer Pain, Part II ONF 17 (5): 751-60, 1990
Spross, J., McGuire, D., Schmitt, R. Oncology Nursing Society Position Paper on Cancer Pain, Part III ONF 17 (6): 943-55, 1990
Issue regarding length of time opiate infusions may hang, approved by D. Kloth and D. Pendleton.
Adopted: December 1993