HHC Health & Home Care Clinical Policy And

HHC HEALTH & HOME CARE Section: 9-27
Infusion Therapy: Continuous Intravenous Narcotic Infusion __RN
PURPOSE:
To improve the pain control obtained by patients with
intractable pain who are unable to achieve pain control
by any other route.
CONSIDERATIONS:
1. Prior to instituting therapy, describe the care
required of the caregiver in the absence of the
nurse. Confirm presence of responsible caregiver in
the home at all times to attend the patient.
2. Preferably, patients referred to home care agency
for continuous infusions of narcotic analgesics
should receive the initial dose of the medication in a
controlled environment. When this is not possible
and the initial dose is administered in the home, the
patient will require observation for the first 24 hours
by either a caregiver or health care provider.
3. A pump is required to administer a continuous
infusion of pain medication to ensure accurate safe
delivery. (e.g., CADD-PCA, CADD PRISM) Verify
that pumps used have safety device to prevent free
flow.
4. Physician's order for medication should include the
following:
a. Name of drug.
b. Total daily dose.
c. Dosage in mg/hr and mg/cc.
d. Baseline rate, cc/hr.
e. Bolus dose in mg/hr., time in between boluses,
and number of boluses allowed per hour.
f. Total volume to be infused.
g. Narcan orders, if applicable.
5. Miscellaneous orders should include:
a. Respiratory parameters to follow, if appropriate.
b. Lab work.
c. Resuscitation status.
d. Caregiver education parameters.
6. Suggested instructions for patients and caregivers
include the following:
a. Use of infusion control device including troubleshooting
alarms.
b. Use, storage, and disposal of controlled
substances.
c. Side effect recognition and management related
to narcotics.
d. Care and management of intravenous access.
7. Morphine sulfate is stable 30 days at room
temperature and should not be mixed with any other
drug unless compatibility is verified by mixing
pharmacist.
8. Dilaudid should not be stored under refrigeration
because of possible precipitation or crystallization
and should not be mixed with any other drug unless
compatibility is verified by mixing pharmacist.
9. Drugs of choice for long-term pain control are
Morphine and Dilaudid.
10. Dosages may vary according to individual patient
tolerance over a period of time. Tertiary cancer pain
should be treated without attempt to prevent
addiction.
11. Central venous access is recommended for
intravenous administration to maintain uninterrupted
level of analgesic in the home.
12. Respiratory depression should be monitored closely
if appropriate. As a rule of thumb, when the
respiratory rate falls below 10/min., decrease the
infusion rate by one-half, and notify the physician.
Narcan may be ordered PRN to counteract
respiratory depression. However, routine use of
Narcan in the home is not recommended because
administration can precipitate acute withdrawal and
proper administration requires continual monitoring
by a health care professional.
13. Adverse reactions to narcotics can include the
following:
a. Drowsiness.
b. Hypotension.
c. Headache.
d. Respiratory depression.
e. Hallucinations.
f. Constipation.
g. Urinary retention.
h. Nausea/vomiting.
i. Allergic reactions (ranging from rash to
anaphylaxis).
14. When analgesic infusions are initiated in the home,
the patient should be monitored for 1-2 hours for s/s
of reactions or respiratory depression. The nurse
should make daily follow-up visits until the baseline
dose is established.
15. Peak action of Morphine Sulfate occurs 20 minutes
after IV administration, 50-90 minutes following
subcutaneous administration.
16. Peak action of Dilaudid occurs 15 minutes after IV
administration, 30-40 minutes after subcutaneous
administration.
17. Suggested usual adult dose:
a. Morphine Sulfate (5-10 mg/hr).
b. Dilaudid (0.5-1.5 mg/hr).
c. Narcan (0.4 mg. may be required at 2-3 minute
intervals, PRN x 3 doses - intramuscular).
18. The above doses will be affected by the following:
a. Patient's tolerance.
b. Type of pump used, dosage settings.
c. Type of access line.
19. Use at least two (2) patient identifiers prior to
administering medications.
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