STANDING PHYSICIAN ORDERS
1.
ASTHMA ATTACK
Evaluate and notify physician of vital signs and respiratory status. If there is any
cyanosis or rapidly declining condition, transport to ER per ambulance STAT.
Inmate should be maintained on the medication he has been taking. When the problem is
mild, albuterol metered dose inhaler may be used at the nurse’s discretion.
2.
ATHLETES FOOT (tinea pedis)
Wet weeping phase, consult physician. Dry, cracking, scaly phase:
Rx
Tolnaftate cream BID until gone (2 weeks).
3.
BRONCHITIS/PNEUMONITIS
If suspected because of severe purulent cough, fever, and patient is obviously ill;
examine chest, throat and neck, and report findings to physician for further care. If in
obvious respiratory distress transport to ER for evaluation, and treatment. If no severe
distress, may initiate amoxicillin or erythromycin.
4.
BURNS
Apply cold compress (not ice) to the burn area for 20-30 minutes.
FIRST DEGREE BURN - area red with no blistering. Usually not necessary to cover
with a dressing. Topical dressing such as Mycitracin Nupercainal may be applied for
comfort.
SECOND DEGREE BURN - area red with blistering. If over 5% of the body
notify the physician for orders.
Rx
5.
1.
2.
3.
4.
5.
6.
Silvadene Cream to burn area and dry sterile dressing.
Tetanus diptheria booster if needed. (if not within past 5 Years).
Tylenol 500-1000 mg q 6 h prn pain or Darvocent N 100 if needed.
Must be re-evaluated by the physician in 48-72 hours.
Notify physician of uncontrolled pain or signs and symptoms of infection.
Change dressing as necessary - cleanse with normal saline, apply Silvadene
cream and dry sterile dressing.
THIRD DEGREE BURN - involves full skin thickness and may have charred
appearance. Cover with a sterile dressing and apply sterile normal saline and refer
immediately to the ER, by ambulance if necessary. The physician shall be notified.
Transport shall not be delayed for dressing application.
CHEST PAIN
If patient with no history of angina or heart disease develops any of the following
symptoms:
1.
Substernal, crushing, or heavy-weight.
2.
Radiation of pain to left arm, shoulder, neck or back of jaw.
3.
Shortness of breath.
4.
Diaphoresis, weakness, vertigo, nausea and vomiting.
You must suspect an acute myocardial infarct. Give nitroglycerin under tongue, plus
administer one half aspirin (163mg) by mouth (unless the patient has a history of aspirin
allergy) and transport immediately to the emergency room. Even if pain is relieved
following nitroglycerin a medical evaluation must be done. Notify nurse/physician of
transport. If a patient who has been taking nitroglycerine prior to incarceration or has a
history of angina or heart disease develops chest pain, give nitroglycerin 0.4 mg SL q 5
minutes until the chest discomfort is relieved or until 3 tablets are used, whichever
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comes first. If chest pain is relieved, observe carefully while awaiting transport to the
emergency room.
6.
COMMON COLD (URI, Allergic Rhinitis Uncomplicated)
Symptoms include stuffy or runny nose, blocked ears, and sinus congestion, sore throat
and cough. May have a low grade fever less than 100 F. Generic cold tablets will be
provided but they may vary depending on availability. The medication may be Actifed,
Sudafed Plus, Contac, Coricidin or others but the ingredients will be similar. If not
improved in seven days refer to doctor or nurse.
Rx
Cold tablets may be given according to the label on the bottle which will usually be one
or two tablets two or three times a day. Cold tablets should not be given to inmates with
high blood pressure. When the cold is complicated by a bad cough a cough suppressant
may be given. It may be given with the cold tablets.
Rx
Give two teaspoons up to 4 times a day with at least four hours between doses.
7.
CONSTIPATION
Rx
If no relief give Milk of Magnesia 30 cc or 1 to 4 Colace tabs.
Further problems and abdominal pain shall be referred to the physician or to ER.
8.
DIABETES
If known diabetic, obtain history from patient and verify with patient physician if
possible.
Rx 1.
2.
3.
4.
Chemstrip
FBS as soon as possible
Maintain usual insulin dose
report to physician
5. Have Monogel available for patient
6. Arrange for appropriate ADA diet
7. Identify diabetic status in patient record at
desk
Insulin Reaction
Decreased blood sugar from too much insulin, missed meals, increased exercise, or
illness. There is a rapid onset which includes fatigue, shakiness, nausea, rapid pulse
and/or cold sweat. Treatment shall consist of administering MONOGEL or sugar. If
there is no response in 15 minutes transport to ER. If the situation is controllable a
chemstrip or other glucose monitor shall be done before and 30
minutes after the MONOGEL administration.
Uncontrolled Diabetic-Coma
Increased blood sugar from missed insulin, increased food intake, or fever and/or
infection. There is a slow onset of hours to days, and may include drowsiness, flushed
face, thirst and loss of appetite. A chemstrip or serum blood glucose may be done and
the physician notified or transfer to ER or contact their private medical doctor.
9.
DISASTER PLAN
The medical staff shall be active participants in the general disaster plan of
the jail and sheriff department. A disaster would be an event which acutely
and adversely affects the health and possibly the life of a large number of
staff and/or prisoners (i.e. riot, fire, epidemic, or natural disaster). Upon
being notified of the disaster at the jail, the first medical staff person on site
shall be responsible for determining the need of additional medical assistance
and take the necessary measures to secure them. They shall then begin to set
up triage areas within the security area assigned by the security staff. Medical
staff shall be assigned by the senior medical staff person on site as they arrive.
The nurse in charge shall be responsible for all medical procedures, if present
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in the facility, until relieved by the physician. An account of all individuals
injured and their disposition shall be maintained on the "Master Casualty List".
After following basic triage and disposition of all injured, the remaining injured
shall be evaluated and treated by the medical staff. An account of all injured
individuals, their treatment disposition, and follow-up will then be tallied and
a copy forwarded to the Sheriff for inclusion in the State Jail Report.
Injury categories and areas of triage shall be established as follows:
IMMEDIATE - Persons sustaining any injury which is or could soon
develop into a life-threatening situation. Persons
needing immediate transport to the hospital.
PENDING -
Persons whose condition necessitates further evaluation
but not as an immediate life-threatening condition (such
as obvious fractures).
DELAYED - Persons who can basically be bandaged or splinted and
later given specific medical treatment (such as sutures,
R/O fractures, etc.)
EXPECTANT - Persons who have sustained such detrimental injuries
that they are not expected to live. This classification
would only be utilized in the event of a total community
disaster involving the jail or in the event transportation
or hospital facilities overload or collapse. This category
shall only be utilized by the physician and his/her decision
alone will implement it and determine those in this category.
10.
DRUG ABUSE AND ALCOHOL DEPENDENCY
When an inmate is know or suspected to be a substance abuser it should be
determined by history what drugs have been involved. If there is a history of
prolonged alcohol consumption, known alcoholism or previous DT's alcohol
withdrawal symptoms should be observed for. If there is difficulty making
this determination the substance abuse staff should be consulted for assistance.
When alcohol withdrawal is anticipated the medical staff must be notified to
begin the medical precautions, which will consist of observations and perhaps
medication.
Whenever an inmate during withdrawal cannot be aroused, is seeing things or hearing things that others
cannot observe, displays uncontrolled anxiety or hostility they must be transferred to the E.R. Whenever
an inmate is withdrawing from known or unknown substances and exhibits a dangerous deteriorating
status (extreme lethargy, unable to arouse, BP over 180 systolic and/or 110 diastolic, pulse rate over 110,
elevated temperature) the inmate must be transferred to the E.R. and the medical staff should be notified.
See procedures for Alcohol Detox.
11.
FEMALES OF CHILD BEARING AGE
All females of child bearing age shall have a pregnancy test if they state that
they are or may be pregnant or if they have signs and symptoms of pregnancy.
Pregnant females shall be referred to a consulting OB-GYN for pre and postnatal
care. The care of nursing mothers shall be referred to the medical director.
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12.
FOREIGN BODIES
Ingestion by a resident of a foreign body such as a razor blade, safety pin,
toothpick etc. may cause no serious problem and may pass per rectum. The
throat shall be examined for signs of injury and no treatment shall be rendered
unless the patient complains of sudden severe, steady pain in the abdomen
and/or other signs of possible bowel obstruction. The physician shall be
notified regarding the ingestion and any further symptoms. The patient in
acute distress shall be transported to the ER.
13.
GASTRITIS SYMPTOMS/ULCER HISTORY
Rx
1.
Maalox (generic equivalent), 30 cc two hours before meals, one hour
after meals and at HS. May have up to seven doses in 24 hours.
2.
Refer to physician at next clinic visit if no relief is obtained.
14.
GASTROENTERITIS
Acute infection of the digestive system usually with cramps, vomiting and
diarrhea and sometimes fever. Observe for dehydration and treat symptoms
with Kaopectate (generic equivalent) 60 cc after each loose or watery bowel movement.
If no relief may use Imodium. Assure adequate intake of water.
15.
HEAD OR BODY LICE
See attached procedure for residents.
16.
HIVES
Rx
17.
Identify as true hives and inform physician. Observe carefully for further
symptoms of allergic reaction.
Benadryl (generic equivalent) 25mg or 50mg qid prn.
HYPERTENSION
Inmates who have been on medication for high blood pressure must be
continued on their medication. Anyone with a history of high blood
pressure must have their blood pressure taken and recorded daily. If
the blood pressure remains normal for 7 days it may be then taken
monthly or on request. The Blood Pressure Evaluation Form must be
completed on admission.
When an elevated blood pressure is noted on admission but there is no
history of having high blood pressure the individual must be observed
for problems and have blood pressure checks twice a day until they
remain normal. The Blood Pressure Evaluation Form must be completed
on admission.
Normal BP is considered to be at or below systolic 140 and diastolic 90. Pressures
between 140/90 and 159/99 may be considered mild, and between 160/100 and 190/110
may be considered intermediate. Blood pressures over 190/110 are considered
emergencies and should be evaluated by a physician or in the E.R. unless they have no
urgent symptoms and a one-time reading that returns to the intermediate range within an
hour or two.
All individuals with persistent elevated BP must have the Blood Pressure Evaluation
Form completed. Anyone with urgent symptoms must be referred to E.R. for evaluation.
A copy of the Blood Pressure Evaluation Form must accompany them with a copy or a
summary of their BP readings.
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Inmates whose blood pressure is consistently in the intermediate range and also have no
urgent symptoms and minimal other symptoms may be started on Dyazide
(triamterene/hydrochlorothiazide) one tablet daily for 5 days. If the blood pressure
returns to normal continue Dyazide and have physician evaluate. If the blood pressure
continues to be elevated add Atenolol 50 mg one tablet po daily and request physician
evaluation. Blood pressure must be recorded at least daily on these individuals until
normal for one week then may be recorded weekly and on request. Patients begun on
Dyazide should have an SMA-7 measured 7-10 days after the initiation of therapy.
Alteratively, patients may be started on Atenolol or Clonidine tablets instead of Dyazide,
with doses increased until blood pressure is ≤ 140/90.
18.
IMPETIGO
Rx
1.
2.
3.
Wash area with soap and water or hydrogen peroxide BID.
Keflex 500 mg po qid or Dicloxacillin 500 mg po qid or Mupirocin 2%
Ointment applied TID for 7 days.
Evaluation by medical director if not responding to treatment within 48
hours
19.
INFLUENZA
Acute infection of the upper respiratory tract with cough, fever and muscle aching. Rx symptomatic. Pain and fever - Tylenol, aspirin or ibuprofen.
Congestion/cough use generic cough and/or cold preparation equivalent.
20.
LACERATION
When an inmate suffers a laceration it should be evaluated by the nurse. If the lesion is
superficial it may be treated by antibiotic ointment. If the lesion is through the skin with
exposed skin edges the inmate should be referred to the ER for evaluation and closure of
the wound.
Lacerations that are well healed may have stitches removed by the medical staff after 10
days or as recommended on the surgical or ER record.
21.
MEDICAL RESTRAINTS
(See the facility protocol.)
22.
MEDICATIONS
1.
All extended medication orders should be reviewed every 30 days by the medical
director to determine if the medication is to be continued.
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2.
Antibiotics should be administered according to the duration stated in the
Standing Orders unless ordered otherwise by the medical director.
3.
All analgesic medications shall be terminated in 15 days unless
specifically ordered for more or less time. A verbal order may be given
for an additional 14 days but beyond 30 days will require re-evaluation.
4.
Medication which enters from outside the system. When an inmate
is admitted and has been taking prescribed medication the nurse evaluator may
continue the medication until the medical director may be contacted. It is
expected that medications prescribed for existing conditions such as
cardiovascular disease, hypertension, metabolic disorders and seizure conditions
shall be continued. Documentation of the medication by physician’s office,
clinic or hospital should be attempted and documented.
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5.
The formulary may be consulted for medication for frequently
encountered conditions. Medications may be prescribed according
to recommended dose and duration.
23.
MENSTRUAL CRAMPS
In most cases for mild cramps ASA, Tylenol or ibuprofen. For more severe or persistent
cramps notify the medical director.
24.
PHARYNGITIS
Rx
1.
Generic throat lozenges, prn to a total of 6 per day.
2
If febrile and injected tonsils or tonsils with purulent discharge or adenopathy,
strep screen and consult with medical director.
3.
Amoxicillin 250mg tid for 10 days or Septra DS one tablet q 12 hr for 10
days.
25.
PULMONARY EMBOLUS
Sudden onset of severe, stabbing chest pain (pain with each breath or cough),
tachycardia, and/or hemoptysis may indicate a pulmonary embolism. Transport to ER
STAT via ambulance.
26.
SCABIES
See procedures
27.
SEIZURES
Turn on side, insert plastic airway if available and mildly restrain only as needed to
prevent injury. If no previous history of seizures transport to ER for evaluation.
Continuous and multiple seizures within 30 minutes or less of each other may indicate
status epilepticus. Transport to ER via ambulance STAT.
28.
SEVERE SEBORRHEA (dandruff)
Dermatitis of scalp causing severe irritation or itching.
Rx
Selsun Blue shampoo 3 times weekly.
29.
SEXUALLY TRANSMITTED DISEASES
Any male complaining of sores, and/or rashes in the genital area or discharge from the
penis will be evaluated by Gen-Probe for gonorrhea and chlamydia, and by blood testing
for syphilis.
Any female complaining of vaginal discharge or pain will be evaluated by Gen-Probe for
gonorrhea and chlamydia, and blood testing for syphilis, and vaginal swab evaluation for
other vaginosis.
Refer to the Sexually Transmitted Disease Management Guidelines of the health
department regarding treatment.
30.
SKIN RASHES
Due to heat or contact with wool blanket or soap. Remove contact. Wash with soap and
water.
Rx
with calamine or caladryl lotion PRN, topical hydrocortisone 1%, or Benadryl 25
or 50mg po q 4 hours prn for itchiness
31.
TETANUS TOXOID
Whenever an inmate or staff member has a penetrating injury to skin or mucus
membranes potential tetanus infection must be considered
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Rx
Tetanus Toxoid
1.
2.
3.
4.
If no history of previous Tetanus immunization give Tetanus
Diphteria Toxoid (Td) 0.5cc and repeat in 4 weeks.
If previously vaccinated but no booster within last 5 years
give Td 0.5cc.
If booster with vaccine containing tetanus toxoid in last 5
years, no booster is needed.
If the patient claims an allergy to Td toxoid notify Medical
Director.
32.
TUBERCULOSIS
See specific policy for TB testing and treatment.
33.
TYLENOL OR ASPIRIN
Tylenol (generic equivalent) 500-1000 mg or aspirin 650 mg may be given for minor
pain and discomfort on request of the inmate.
34.
UNRESPONSIVENESS OR PARALYSIS
Any occurrence of unresponsiveness, paralysis, sudden mental confusion or the sudden
onset of a severe headache shall be transported to the ER via ambulance STAT.
35.
URINARY TRACT INFECTION
For burning and frequency of urination a urinalysis will be done. The lab will be
informed to culture if there is greater than 3-5 WBC. Clean catch midstream urine
samples are to be used. If there is any penile drip a Gen-Probe is to be done for
gonorrhea and chlamydia. If patient has costovertebral angle tenderness or back pain,
contact the physician without waiting to assess response to therapy.
If the urine reports more than 5-10 WBC's the inmates should be placed on Bactrim DS
one tablet bid for 5 days. Alternatively, if the patient is allergic to sulfa but not to
penicillin, use amoxicillin 500 mg one tablet po tid for 5 days. . If symptoms have not
cleared in 5 days then contact the physician. One week after the medication is finished
the urine should be checked again for WBC's.
36.
VENEREAL WARTS
Refer patient to STD nurse at next clinic time. May be treated according to standard
orders of the STD Management Guidelines.
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