Client Name: ________________________
DOB: _________________________
ROUTINE STANDING ORDERS
Person Served:
Caregivers are responsible to read all medication package direction and labeling in accordance with policy and procedures and notify
nurse or physician of any concerns or questions.
FEVER, PAIN, DISCOMFORT
(For temporary relief of minor aches, pains, headaches, menstrual discomfort and fever above 100 degrees orally. Not for GI distress.)
Acetaminophen (Common brand name – Tylenol): 325mg tablets – 2 tablets (650mg) by mouth every 4 hrs. as needed.
Aspirin: 325mg tablets – 2 tablets (650mg) by mouth every 4 hrs. as needed. May cause stomach irritation. Take with food.
Note: Notify nurse or physician if fever is 102 degrees F or higher orally or if fever persists longer than one day with no other
symptoms.
Doctor/Provider:
Approve________
Disapprove________
DIARRHEA
(Urgent, reoccurring watery stool)
Loperamide (Common brand name – Imodium AD): See package directions for dosing.
Note: For mild diarrhea avoid solid foods and dairy products and give clear liquids (tea, water, apple juice, broth, Jell-O, 7-Up).
Advance diet to soft food as tolerated (cereal, toast, crackers, bananas, rice). Notify nurse or physician if diarrhea is
severe, is associated with severe abdominal cramps/pain, is associated with fever, is associated with taking an antibiotic, or
persists for longer than 48 hours.
Doctor/Provider:
Approve________
Disapprove________
CONSTIPATION
(Not for GI distress such as nausea, vomiting, heartburn, or abdominal pain)
Milk of Magnesia: 2 tablespoons by mouth at bedtime, followed by a glass of water.
Note: Check client’s medication sheet for current protocol. If not instructions, administer on third day of no bowel movement.
Check bowel status the next day and record results. Notify nurse or physician if not results. Notify nurse or physician of
severe abdominal pain, nausea, vomiting, or rectal bleeding.
Caution: Do not administer to clients with kidney disease. Check with nurse or physician first.
Doctor/Provider:
Approve________
Disapprove________
ANTACID/ANTIFLATULANT
(Heartburn, gas pain. Not for vomiting)
Magnesium/Aluminum/Simethicone combination (Common brand names – Riopan Plus, Maalox Plus, Mylanta II – liquid or
tablets): See package directions for dosing.
Note: Do not administer within 2 hours of Tetracycline, enteric coated medications or psychotropic medication. Check with
nurse, physician, or pharmacist. Check with nurse or physician if condition does not respond within one day.
Caution: Do not administer to clients with kidney disease. Check with nurse or physician first.
Doctor/Provider:
Approve________
Disapprove________
EAR WAX
Carbamide Peroxide 6.5%: (Common brand name – Debrox Ear Drops): 5 drops in both ears twice a day for up to four days.
Note: Do not use if having ear drainage or discharge, ear pain, irritation or rash in the ear, dizziness or has a hole, perforation, or
injury to the ear or has had recent ear surgery. Notify nurse or physician.
Doctor/Provider:
Approve________
Disapprove________
NASAL CONGESTION
Pseudoephedrine (Common brand name – Sudafed): 60mg by mouth every 4-6 hours as needed.
Note: Notify nurse or physician if nasal congestion is associated with a fever or persists for longer than 3 days.
Caution: Do not administer to clients with high blood pressure, heart disease, diabetes mellitus, thyroid disease, enlargement of
the prostate gland or if taking a drug containing MAO inhibitor. Check with nurse or physician first.
Saline Nasal Spray: See package for directions for dosing.
Doctor/Provider:
Approve________
Disapprove________
COUGHS
Guaifenesin 100mg/Dextromethorphan 10-15mg (Common brand name – Robitussion DM): 2 teaspoons by mouth every 4-6
hours as needed.
Note: Notify nurse of physician if cough is associated with fever, rash, persistent headache or if cough persists longer than two
days.
Caution: Do not administer to clients with asthma, chronic bronchitis, emphysema or if the cough is accompanied with excessive
phlegm. Do not administer to clients taking a prescription drug for high blood pressure or a drug for depression containing
a MAO inhibitor. Check with nurse or physician first.
Doctor/Provider:
Approve________
Disapprove________
MINOR WOUNDS, CUTS, ABRASIONS
Bacitracin Ointment: Clean wound and apply a thin film of Bacitracin once or twice a day. Cover with dry gauze dressing or a
band-aid.
Note: Change dressing once or twice a day and if the dressing becomes wet or dirty, or as directed by nurse or physician. Notify
nurse or physician if signs of infection develop. Signs of infection may include redness, pus, swelling, or warmth to the
area.
Doctor/Provider:
Approve________
Disapprove________
MILD FUNGAL INFECTIONS
(Athletes Foot or Ring Worm)
Miconazole Nitrate 2% (Common brand name – Micatin), Tolnaftate (Common brand name – Tinactin), Lotrimin Cream
0.5%: Clean affected area and apply liberally twice a day until clear. Minimum length of treatment is 5-7 days.
Note: Notify nurse or physician if no improvement after three days or if condition does not resolve in two weeks.
Doctor/Provider:
Approve________
Disapprove________
MINOR SKIN RASHES/MILD DERMATITIS
Hydrocortisone Topical 0.5% or 1% (Common brand name – Cortaid): Clean affected area and apply sparingly 2-3 times per
day.
Note: Notify nurse of physician if affected area is extensive, any open wounds, any signs of infection, condition does not respond
to treatment within 2 days or rash is spreading.
Caution: Avoid using medication on the face or near the eyes or mouth.
Doctor/Provider:
Approve________
Disapprove________
MINOR SUNBURNS/MINOR BURNS
**Call nurse or physician for all burns**
Sun block: Sun block SPF 50 is to be applied at least 30 minutes prior to a client spending time outside, especially in the
summertime and on a sunny day. It should be re-applied as needed for extended time outdoors (avoiding the eyes). If a
burn blisters it needs medication assistance (PCP, Urgent Care, or ER).
Doctor/Provider:
Approve________
Disapprove________
INSECT BITES/POISON IVY/POISION OAK
Calamine Topical: Clean affected area and apply 3-4 times daily.
Note: Notify nurse or physician if affected area is severe, extensive, involves the face or if not improvement within five days.
Doctor/Provider:
Approve________
Disapprove________
ANNUAL INFLUENZA VACCINATION
I authorize this client to have an annual influenza vaccination.
Doctor/Provider:
Approve________
Disapprove________
POISONING
Contact Poison Control Immediately: Rocky Mountain Poison Control 1-800-332-3073 or National Poison Control 1-800-222-1222.
Administer Syrup of Ipecac ONLY if instructed by Poison Control to induce vomiting.
ALTERNATIVE ORDERS:
The above medication may be used during the next year on an as needed basis.
_______________________________________
PHYSICIAN/PROVIDER’S SIGNATURE
__________________
DATE