Physical Examination And Medical History Form (Page 3 of 4) in pdf

Phone: 763-479-3555

3675 Iduhapi Road

Fax: 763-479-2605

P.O. Box 308

Website:

Loretto, MN 55357-0308

STANDING ORDER FOR OVER THE COUNTER

MEDICATIONS

NAME _____________________________ ALLERGIES ____________________

The following maybe given on a PRN basis. Medications contraindicated will be noted by the

physician. Equivalent generic or store brands may be used. Seasonal supplies will be

stocked PRN. Follow all instructions listed. Chart medications administered on the Medication

Sheet. Write the reason for giving and the participant's response to the medication in the Health

Progress Notes.

FEVER/PAIN/MENSTRUAL CRAMPS

Notify the nurse of a temperature above 100 degrees and pain not relieved by medication.

Tylenol (Acetaminophen) 500 mg Extra Strength tablets (1-2 tablets) q 6 hrs prn NOT TO

EXCEED 8 TABLETS IN 24 HOURS

Tylenol Elixir (Acetaminophen Elixir) 4 tsp. (650 mg) (o) q 4 hrs prn or

Ibuprofen 200 mg (o) 1-2 tablets or capsules q 4 hrs prn; do not exceed 6 tablets in 24 hrs.

COLD/DISCOMFORT FROM COLD/SORES THROATS

Notify the nurse of temperature above 100 degrees or below 97.6 degrees; if participant has been

exposed to strep infection, persistent cough, earache chest pain or congestion; skin rash; or any

symptom lasting more than 3 days.

Claritan (Loratadine) 1 tab every 24 hours X 3-5 days PRN 10mg tablets for congestion.

Robitussin DM (Dextromethorphan and Gualfensin) (o) 2ttsp. q 4 hrs prn cough. Do Not

exceed 6 doses in 24 hrs.

Chloraseptic Lozenges (o) for sore throat. Follow directions on package.

CONSTIPATION

Notify the nurse if participant has gone three days without having a BM. Notify the nurse if

participant does not have a BM within 24 hours after giving laxative. Under direction of the

nurse or MD may give:

Milk of Magnesia (o) 2 tablespoons qd prn. (Usually given at HS)

DIARRHEA

Notify the nurse. Avoid milk products. Give clear liquids. Give clear liquids such as cola, 7-up,

Gatorade, Kool-Aid, Popsicle's, tea or apple juice. Under direction of nurse or MD may give:

Imodium (Loperamide) 2 mg (o) 2 capsules or tablets after 1

loose bowl movement, followed

by one tablet or capsule after subsequent loose bowel movement. No more than 4 caps per day.

Do not use for more than 2 days.

INDIGESTION/NAUSEA/HEARTBURN

Notify nurse or symptoms unrelieved by medication or if vomiting occurs.

Maalox (Alumina and Magnesia) 15 cc (o) q 3-4 hrs prn

Physical Examination And Medical History Form Page 3