STANDING ORDERS FOR ACUTE PAIN NURSE SPECIALIST (APNS) and ACUTE PAIN NURSES (APN)

Acute Pain Nurse Specialist: M.Sc Nursing (Lecturer and above)

Acute Pain Nurse: B.Sc Nursing (≥ 2 years of experience) or Diploma Nursing (≥ 5 years of experience)

I. Drug administration and titration:

Administer the following drugs during pain emergencies, as per the drug administration guidelines (attached as addendum), on verbal orders with subsequent written orders by the doctor.

a. Inj. Ephedrine I.V.b. Inj. Morphine I.V.c. Inj. Tramadol I.V. d. Inj. Voveran I.V. e. Inj. Ketanov I.V.f. Inj. Naloxone I.V. g. Inj. Ondansetron I.V.

II. Procedures that can be performed:

1. Sensory and motor block assessment for patients on epidural analgesia.2. Removal of epidural catheter after discontinuing the therapy.3. Change of epidural catheter site dressing.4. Insertion and removal of subcutaneous port for analgesic administration.5. Intermittent catheterization using red rubber catheter for urinary retention in patients on epidural analgesia / PCA.

III. Additional standing orders for Acute Pain Nurse Specialist (subject to the presence of adequate patient monitoring equipment):

1. Perform one dose titration per patient for epidural infusion during episodes of inadequate analgesia.2. Perform one change of lockout interval per patient for PCA during episodes of inadequate analgesia.3. Purge epidural drugs, either to check catheter patency or for analgesia.4. Adjust epidural catheter during episodes of inadequate analgesia.

DRUG ADMINISTRATION GUIDELINES1. Inj. Ephedrine I.V. a. Dosage: 0.25-0.5 mg/kg (adult – 10-25mg, children – 3mg/kg/day in 4 to 6 divided doses) b. Available form: 30 mg/mlc. Mode of administration: Dilute 1 ampoule in 4 ml of sterile water and administer 1ml (6mg) as slow bolus. Repeat the next bolus (1ml) in 5 to 10 minutes if required.d. Specific considerations: Monitor for arrhythmias and tachycardia.

e. Contraindications: Coronary artery disease, pre-existing arrhythmias, cardiovascular diseases

2. Inj. Morphine I.V.

a. Dosage: 0.1-0.2mg/kg (adult – 2.5-10mg, children – 0.02 to 0.2mg/kg)

b. Available form: 10 mg/ml

c. Mode of administration: Dilute in 3-4 ml of sterile water

d. Specific considerations: Monitor for pruritis, nausea, vomiting, constipation, urinary retention and respiratory depression. Monitor respiratory rate and sedation score.

e. Contraindications: Hepatic or renal failure, head injury. Use with caution in geriatric and debilitated patients.

3. Inj. Tramadol I.V.

a. Dosage: 2-3 mg/kg (adults - 50-100mg every 4 to 6hours, children – 1-2 mg/kg).

b. Available form: 50 mg/ml

c. Mode of administration: Administer bolus as slow I.V.

d. Specific considerations: Monitor for nausea, vomiting, dizziness and headache. Use with caution for patients with head injury.

e. Contraindications: Acute alcohol intoxification, use of hypnotics.

4. Inj. Naloxone I.V.

a. Dosage: Adults - 0.1-0.2 mg, Children – 0.005-0.01mg

b. Available form: 0.4 mg/ml

c. Mode of administration: Dose can be repeated at 2 to 3 minute intervals until the desired response is obtained.

d. Specific considerations: Monitor for nausea and vomiting. Use with caution in hepatic and renal impairment.

e. Contraindications: Liver failure

Reference: IDR drug formulary, Medclik and WHO model list of essential medicines, http://www.who.int/medicines/publications/essentialmedicines/en/

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Dr. C.E. Eapen, Dr. Jayarani Premkumar, Medical Superintendent. Nursing Superintendent