Opioid Range Orders: Essential to Safe Pain Management

Chris Pasero, MS, RN-BC

Disclosures

August 15, 2012

Clinical Presentation: Postoperative Pain in a Child

This patient is a 12-year-old girl with postoperative pain following an exploratory laparotomy and appendectomy 1.5 hours ago. She is admitted to the pediatric clinical unit after a 60-minute stay in the postanesthesia care unit (PACU).

The nurse who admits the patient to the clinical unit obtains the following information:

  • The patient is an otherwise healthy girl with a recorded weight of 90 lb and height of 5'1".

  • Vital signs:

    • Tympanic temperature: 98°F

    • Pulse: 80 beats/min

    • Respiration: 20 breaths/min, deep and regular; oxygen saturation on room air (using pulse oximetry), 98%

    • Blood pressure: 112/72 mm Hg

  • Skin is pink and warm.

  • Abdominal dressing is dry and intact.

  • The patient is awake and alert.

  • The patient transfers from stretcher to bed with minimal assistance, but grimaces and says "ouch, ouch" when she moves.

  • The patient points to her abdominal incision and describes the incision and area around it as "very sore, stings, and hurts a lot." She rates the intensity of pain as 7 using the 0-to-10 Faces Pain Rating Scale-Revised (FPS-R). She is trying to hold back tears and looks distressed.

  • The patient's comfort-function goal, established preoperatively, is 2 out of 10 (FPS-R) to ambulate with ease.

  • Her mother, father, and older sister are present.

Postoperative Pain

Postoperative pain management orders:

  • Acetaminophen 650 mg intravenously (IV) every 6 hours for 2 doses (first dose preoperatively), then switch to oral acetaminophen 650 mg every 6 hours if able to tolerate fluids. Notify the surgeon if unable to tolerate fluids.

  • Ketorolac 7.5 mg IV every 6 hours.

  • Morphine 1-4 mg IV every 2 hours as needed for pain.

  • Warm water-circulating pad to abdomen.

Analgesics administered in preoperative holding area and in the PACU:

  • First dose of IV acetaminophen 650 mg was given preoperatively.

  • Ketorolac 7.5 mg IV was given on admission to the PACU.

  • Fentanyl 25 μg IV was given on admission, and an identical dose was given 10 minutes later to reduce pain rating from 10 to 4 (FPS-R). Last dose was given 20 minutes before discharge from the PACU.

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