MMSR Manual 2021-Standard 4 (Pharmaceutical Services).pdf

Standard 4 PHARMACEUTICAL SERVICES FIGURE 4-1 Drug Formulary FIGURE 4-2 ACLS Drugs List FIGURE 4-3 Standing Orders Guidelines for Nurses FIGURE 4-4 Examination & Treatment Protocol for Nurses 79 80  SURVEY AND C...

Standard 4 PHARMACEUTICAL SERVICES FIGURE 4-1 Drug Formulary FIGURE 4-2 ACLS Drugs List FIGURE 4-3 Standing Orders Guidelines for Nurses FIGURE 4-4 Examination & Treatment Protocol for Nurses 79 80  SURVEY AND COMPLIANCE REVIEW REPORT Instructions: Tick ()) Yes or NO = Does not Meet Standards or write “NA” where not Applicable Item Standards Responsible Date: Comments Code Yes No NA 4.0 PHARMACEUTICAL SERVICES 4.A DRUG FORMULARY The HCP shall ensure that their medical facilities have a drug formulary. This HCP formulary shall contain a wide spectrum of drugs enabling patients to be treated for 4.A.1 minor ailments, emergencies, and stabilization prior to transfer to definitive medical care facility. The selection of drugs and quantity for each DRUG CATEGORY depends on the HCP facility’s operational needs and it is determined by the responsible physician. At a 4.A.2 minimum the drug formulary include, but are not limited to:For more information, Refer to Figure 4-1. 1. Analgesic (non-narcotic) agents at a minimum include, but are not limited to: HCP a. Oral analgesic/antipyretic tablets (e.g., acetaminophen). b. Oral analgesic/anti-inflammatory, non-steroidal anti-inflamma- tory drug (NSAID), tablets/capsules. c. Injectable analgesic/anti-inflammatory, NSAID. d. Analgesic topical cream and/or ointment. 2. Muscle relaxant, tablets. HCP 3. Urinary tract infection (UTI), analgesic/anesthetic agents, oral tablets/capsules. HCP 4. Antibiotic agents at a minimum include, but are not limited to the followings: HCP a. Oral antibiotic agent tablets/capsules. b. Topical antibiotic ointment for cuts, scrapes, abrasions, insect bites, scratches, etc. c. Topical antibiotic ointment for burns. 5. Antacid oral agents at a minimum include, but are not limited to: HCP a. Antacid chewable tablets.  SURVEY AND COMPLIANCE REVIEW REPORT Instructions: Tick ()) Yes or NO = Does not Meet Standards or write “NA” where not Applicable Item Standards Responsible Date: Comments Code Yes No NA 4.0 PHARMACEUTICAL SERVICES b. Antacid suspension. 6. Gastric (stomach) acid control agents at a minimum include,: HCP a. Oral H2 blocker, tablets. b. Injectable H2 blocker (IV and/or IM use). 7. Antidiarrheal oral agent, capsules. HCP 8. Antispasmodic agents at a minimum include, but are not limited to: HCP a. Oral antispasmodic, tablets. b. Injectable antispasmodic, IM, IV. 9. Antiemetic’s (treat nausea and vomiting) agents at a minimum include: HCP a. Oral antiemetic, tablets. b. Injectable antiemetic, vial. 10 Ant parasitic chewable tablets. HCP 11 Laxative oral tablets/liquid. HCP 12 Bronchodilators agents at a minimum include, but are not limited to: HCP a. Nebulizer aerosol delivery solution. b. Inhalers. 13 Stimulant (crushable ampule, respiratory stimulant for inhalation only). HCP 14 Beclomethasone disproportionate, oral inhalation agent. HCP 15 Nasal agents at a minimum include, but are not limited to: HCP a. Antihistamine nose drops and/or spray. b. Anti-infective steroid combination drops. 16 Nasal decongestant tablets/capsules. HCP 17 Beta Blocker agent, tablets. HCP 18 Antitussive (cough suppressant) agent, syrup, bottle. HCP 19 Antihistamine agents at a minimum include, but are not limited to: HCP 82  SURVEY AND COMPLIANCE REVIEW REPORT Instructions: Tick ()) Yes or NO = Does not Meet Standards or write “NA” where not Applicable Item Standards Responsible Date: Comments Code Yes No NA 4.0 PHARMACEUTICAL SERVICES a. Oral, tablets/capsules. b. Injectable to relieve severe allergic reaction(s). 20 Steroidal anti-inflammatory agents at a minimum include, but are not limited to: HCP a. Oral steroid, tablets. b. Injectable steroid, IV and/or IM use. 21 Anesthetic agents at a minimum include, but are not limited to: HCP a. Injectable local anesthetic solution. b. Topical local anesthetic ointment, tube. c. Oral (gel) local anesthetic, bottle. 22. Anticonvulsants (non-controlled) agent, IV and/or IM use. HCP 23. Anticoagulant, vial. HCP 24. Vasodilator (Nitrate) agent, sublingual, tablets. HCP 25. Antidiabetic (diabetes control) agents at a minimum include,: HCP a. Oral glucose powder. b. Injectable dextrose 50%, prefilled syringe. c. Injectable ant hypoglycemic agent (glucagon). d. Injectable hyperglycemic agents (insulin). d.1 Insulin Regular 100 U/ml 10 ml vials. d.2 Insulin Human Isophane suspension. d.3 Oral hypoglycemic tablets (Glucophage). 26. Ophthalmic agents at a minimum include, but are not limited to: HCP a. Antibiotic ophthalmic agents at a minimum include: a.1 Eye drops. a.2 Eye ointment. b. Antihistamine eye drops. 83 c. Anesthetic eye drops.  SURVEY AND COMPLIANCE REVIEW REPORT Instructions: Tick ()) Yes or NO = Does not Meet Standards or write “NA” where not Applicable Item Standards Responsible Date: Comments Code Yes No NA 4.0 PHARMACEUTICAL SERVICES d. Diagnostic agents eye drops, Myotic/ Mydriatic (e.g., Pilocarpine HCL-2%). e. Other eye drops (i.e., irrigation, dry eye, eye wash). 0.27 27. Vaccination agents at a minimum include, but are not limited to: HCP a. Tetanus immunoglobulin, IM use. b. Tetanus toxoid, IM use. 28. Intravenous (IV) fluids at a minimum include, but are not limited to: HCP a. Dextrose infusion, bag. b. Lactate Ringer (LR) infusion c. Sodium Chloride (NS) infusion. 29. Rehydration oral agent, sachet. HCP 30. Diuretics (treat water retention) agents at a minimum include: HCP a. Oral diuretic, tablets. b. Injectable diuretics. c. Infusible diuretic solution, bag. 31. External/topical agents at a minimum include, but are not limited to: HCP a. Antibiotic-anesthetic-steroid, hemorrhoid ointment/cream. b. Corticosteroid topical cream, tube. c. Antipruritic topical cream and/or lotion, tube and/or bottle. d. Antifungal topical cream, solution and/or powder e. Antiseptic cleanse/scrub topical solution, bottle. f. Antiseptic skin cleanser/scrub (i.e., surgical hand scrub). g. Antiseptic topical solution (i.e., isopropyl alcohol, betadine, povidone-iodine, etc.). h. Antiseptic swab (alcohol sachet). i. Emollient/lubricant, white petroleum KY jelly, tube. 84  SURVEY AND COMPLIANCE REVIEW REPORT Instructions: Tick ()) Yes or NO = Does not Meet Standards or write “NA” where not Applicable Item Standards Responsible Date: Comments Code Yes No NA 4.0 PHARMACEUTICAL SERVICES j. Optic drops (cleanser ear drops). 32. Diluents agents at a minimum include, but are not limited to: HCP a. Sodium Chloride (NS), 10/20 ml ampules. b. Sterile water for injection, 10/20 ml ampules. 33. Miscellaneous agents at a minimum include, but are not limited to: HCP a. Adhesive remover for surgical/regular tape or dressing removal. b. Silver nitrate applicators. c. Throat lozenges. d. Glycerin bottle. (For list of ACLS drugs. Refer to Figure 4-2) 4.B DRUG ADMINISTRATION The HCP shall ensure that their medical facilities have a drug dispensing HCP guidelines (written in a clear format) for nurses who are authorized to administer 4.B.1 and dispense certain drugs in the absence of a physician and at a minimum it include the following: 1. A list of all medications/drugs that clearly stipulate which medi- cations can HCP be administered by the nurse as standing order (SO) or routine order (RO), and which ones require a physician’s consultation telephone order (TO). 2. Standing order guidelines for nurses. HCP For more information, Refer to Figure 4-3 and Figure 4-4. 3. Specific procedures to be followed for all TOs including documentation HCP process. 4. Specific criteria for privileging nurses to administer and dispense HCP medications listed in the drug formulary and to administer the drugs in the emergency response bag. At a minimum: a. There is evidence that the nurse successfully completed a drug familiarization competency program. 85  SURVEY AND COMPLIANCE REVIEW REPORT Instructions: Tick ()) Yes or NO = Does not Meet Standards or write “NA” where not Applicable Item Standards Responsible Date: Comments Code Yes No NA 4.0 PHARMACEUTICAL SERVICES b. There is a drug information reference system available on-site or remotely (e.g., physician/ pharmacist consultation/online drug information site/drug inserts file/pharmacology book). 4.C DRUG DISPENSING The HCP shall ensure that their medical facilities dispense all medications/ drugs as HCP 4.C.1 follows: 1. In a suitable container. HCP 2. At a minimum, labeled with the following information: HCP a. Patient’s name and ID number. b. Date. c. Drug’s name and strength. d. Dispensing instructions (e.g., one (1) tablet three times a day after meals). 4.D DRUG STORAGE The HCP shall ensure that their medical facilities have an adequate storage and HCP inventory control system with appropriate checklists in place to facilitate the 4.D.1 dispensing and inventory control of all medications/ drugs in stock, as follows: 1. Ensure that all drugs/medications listed are: Available and Current HCP 2. Minimum Stock Levels (MSL) are maintained at all times. HCP 3. Rotated (arrange shorter expiry date in front). HCP 4. Inventory/expiration check date is conducted on monthly basis. Log is HCP available upon request. 5. All medications/drugs shall be stored according to manufacturer's HCP recommendations, as follows: 86  SURVEY AND COMPLIANCE REVIEW REPORT Instructions: Tick ()) Yes or NO = Does not Meet Standards or write “NA” where not Applicable Item Standards Responsible Date: Comments Code Yes No NA 4.0 PHARMACEUTICAL SERVICES (Cont.) a. In an air conditioned room. b. On shelves above floor level or in a lockable cupboard. c. Appropriately organized and identified in a systematic way (alphabetic order or drug group). d. Oral Medications and external use medications are stored separately. e. Narcotics/controlled substances, if available, are stored under double lock. 6. Temperature sensitive drugs are stored in a dedicated fridge as follows: HCP a. Temperature is maintained at: 2 to 8 Celsius (C): [36- 45 Fahrenheit (F)]. b. Temperature is monitored and recorded twice daily. c. Fridge is cleaned twice a month. 4.E DRUG DISPOSAL The HCP shall ensure that their medical facilities have a system in place for the HCP 4.E.1 safe disposal of expired drugs and it is implemented as follows: 1. Expired medications/drugs are handled as follows: HCP a. Placed into a box. b. Box is labeled “expired.” c. Stored separately from other medications/drugs. There is evidence that expired medications/drugs were sent to supplier for HCP 4.E.2 proper disposal or other disposal system that meets MOH regulations. Documentation is available upon request. The HCP shall ensure that their medical facilities’ staff is familiar with and HCP adhere to MOH regulations in regards to transportation, dispensing, 4.E.3 administration and disposal of Narcotics/Controlled substances, where applicable. 87  DRUG FORMULARY - Figure 4-1 Level A&B Level C&D Generic Dosage Order Class Use Minimum Qty Minimum Qty Absorbable gelatin 2 cm by 6 cm by 7 mm sponge, 4 per BT. SO Hemostatic Topical hemostatic 10 x Acetaminophen 350 mg suppository SO Rectal medication Analgesic 10 6 Acetaminophen 500 mg tablet SO Analgesic Analgesic 3,000 1,000 Acetaminophen with Codeine 500 mg A / 10 mg C tablet TO Analgesic Analgesic 200 100 Acetylcysteine 200 mg / ml, 10 ml ampule for iv infusion TO Miscellaneous Antidote (Tylenol) 5 x Analgesic/Ant-inflam- Acetylsalicylic Acid 325 or 500 mg tablet SO NSAID 300 100 matory Adhesive Remover Spray SO First Aid Supplies Miscellaneous 2 1 Aerochamber Aerosol delivery chamber TO Miscellaneous Miscellaneous 5 2 Albuterol Sulfate 2 mg tablet TO Bronchodilator Anti-Asthmatic 300 x Albuterol Sulfate 20 ml respirator solution TO Bronchodilator Anti-Asthmatic 6 2 Albuterol Sulfate Oral Inhaler TO Bronchodilator Anti-Asthmatic 30 5 Alcohol Isopropyl 70% solution, 250 ml bottle SO Antiseptic Miscellaneous 6 4 Alcohol Isopropyl Large sachet swabs SO Antiseptic Miscellaneous 500 300 Algesal 40 gm tube SO Other Agents Miscellaneous 50 20 Ammonia 0.3 ml crushable ampoule SO Miscellaneous Stimulant 6 6 Amoxicillin 250 mg capsule TO Antibiotic Antibiotic 500 200 Antacid Tablet Chewable tablets SO Antacid Antacid 200 200 Anusol suppository SO Rectal medication Anesthetic 100 30 Atenolol 50 mg tablet TO Cardiovascular Beta Blocker 300 x Augmentin 375 mg capsule TO Antibiotic Antibiotic 500 200 Azithromycin 250mg tablets TO Antibiotic Antibiotic 120 60 Bacitracin Zinc ointment, 500 units / gm SO Anti-infectives Antibiotic 40 10 Benylin expectorant 120 ml bottle SO Expectorant Cough Syrup 60 30 88  DRUG FORMULARY - Figure 4-1 Level A&B Level C&D Generic Dosage Order Class Use Minimum Qty Minimum Qty Betamethasone valerate 0.1% cream, 30 gm tube TO Corticosteroid Steroid 20 10 Bisacodyl suppository SO Rectal medication Laxative 10 10 Bisacodyl 5 mg tablet SO Laxative Laxative 100 100 Blood test strip Blood glucose test strip SO Miscellaneous Diagnostic agents 150 100 Cafergot caffeine100 mg/ ergotamine 1mg TO Analgesic Anti-Migraine 60 x Calamine Lotion 100 ml bottle SO Other Anti-pruritic 12 6 Carbamide peroxide 6.5% otic drops SO Cleanser Cleanser 12 4 Cefaclor 250 mg capsule TO Cephalosporin Antibiotic 600 200 Cefazolin sodium 500 mg/vial for iv or im use TO Cephalosporin Antibiotic 4 2 Ceftriaxone 1 gram vial for im or iv use TO Cephalosporin Antibiotic 6 x Cetrizine 10 mg tablet SO Antihistamine Antihistamine 400 200 AMPLE Chlorhexidine gluconate 4% scrub, 500 ml bottle SO Antiseptic Cleanser 6 6 Cinchocaine HCl 1% ointment, 20 gm tube SO Rectal medication Anesthetic 10 10 Ciprofloxacin 250 mg tablet TO Fluoroquinolone Antibiotic 300 x Cloramphenicol 0.5% ophthalmic drops, 10 ml dispenser TO Ophthalmic Antibiotic 5 5 Clotrimazole 1% cream, 20 gm tube SO Anti-infective Anti-fungal 20 10 Clotrimazole 1% solution, 20 ml bottle SO Anti-infective Antifungal 10 10 Colchicine 0.5 mg tablet TO Analgesic Anti-Gout 60 x Cromolyn sodium 2 % solution, 10 ml dispenser TO Ophthalmic Antihistamine 20 x Cromolyn sodium 2% solution, 30 ml spray bottle TO Nasal Preparation Antihistamine 12 x Daktacort cream 2% miconazole/1%hydrocortisone, 15g tube TO Combination Antifungal/steroid 10 6 Dextromethorphan HBr 100 ml bottle SO Antitussive Cough Syrup 100 25 Dextrose 5% 1 Litre Bottle/Bag TO Caloric Agent Replacement Fluid IV 5 3 Dextrose 50% 50 % IV solution, 50 ml Pre-filled syringe TO Caloric Agent Carbohydrate 5 3 89  DRUG FORMULARY - Figure 4-1 Level A&B Level C&D Generic Dosage Order Class Use Minimum Qty Minimum Qty Analgesic/Anti-inflam- Diclofenac 50 mg tablet TO NSAID 600 100 matory Analgesic/Anti-inflam- Diclofenac suppository TO NSAID 20 10 matory Dextromethorphan HBr 100 ml bottle SO Antitussive Cough Syrup 50 25 Dimenhydrinate 50 mg tablet TO Anti-vertigo Anticholinergic 200 60 Diphenhydramine HCL 25 mg capsule TO Antihistamine Antihistamine 200 60 Doxycycline 100 mg tablets or capsules TO Anti-infective Antibiotic 200 x Dyazide 50 mg triamterene/25 mg hydrochlorthiazide TO Diuretic Diuretic, K Sparing 40 x Erythromycin 0.5% ophthalmic ointment, 3.5 gm tube TO Ophthalmic Antibiotic 50 4 Erythromycin 250 mg tablet TO Antibiotic Antibiotic 200 x AMPLE Famotidine 40 mg tablet TO Ulcer Disease H2 blocker 100 30 Fleet enema 133 ml squeeze bottle TO Rectal medication Laxative 6 6 Fluorescein sodium single use applicator SO Ophthalmic Diagnostic agents 50 20 Fluticasone Oral Inhaler 50mcg/actuation TO Bronchodilator Anti-Asthmatic 10 x Fluticasone nasal spray TO Corticosteroid Anti-inflammatory 12 x Folic acid 5 mg tablet TO Anti-anemic Anemia 100 x Fosphenytoin sodium 50 mg/ml, 10 ml ampule, for iv or im use TO Anticonvulsant Anticonvulsant 10 2 Framycetin sulfate 1% impregnated gauze pads 10x10 cm SO Anti-infective Antibiotic 10 10 Furosemide 10 mg / ml vial, 2 ml amp TO Diuretic Diuretic 10 4 Furosemide 40 mg tablet TO Cardiovascular Diuretic 200 Glucometer Control agent Control solution (high, med, low) SO Miscellaneous Diagnostic agents 5 3 Glucometer Lancets 100/box SO Miscellaneous Diagnostic agents 200 100 Glucometer Reagent sticks Reagent sticks, 25 per pack SO Miscellaneous Diagnostic agents 200 100 Glucophage 500 mg tablet TO Biguanide Diabetes 200 100 90  DRUG FORMULARY - Figure 4-1 Level A&B Level C&D Generic Dosage Order Class Use Minimum Qty Minimum Qty Glucose powder As directed SO Miscellaneous Hypoglycemia 3 2 Glyburide 5 mg tablet TO Sulfonylurea Diabetes 300 x Glycerin 4 Oz bottle SO Powders Solvents Miscellaneous 4 4 Guaifenesin syrup 200 ml bottle SO Antitussive Cough Syrup 60 25 Histoacryl (Dermabond) 0.5ml crushable ampoule TO Skin Adhesive Wound closure 6 4 Haloperidol 5mg tablets TO Psychotropic Antipsychotic 10 x Haloperidol 5mg/ml Inj. TO Psychotropic Antipsychotic 10 x Heparin Inj. 5,000 units/ml - 10 ml vial TO Anticoagulant Anticoagulant 4 x Hydrocortisone 100mgm for IV, IM Use TO Corticosteroid Steroid injection 5 3 Hyoscine-N-butylbromide 10 mg tablet TO Antispasmodic Antispasmodic 800 200 Hyoscine-N-Butylbromide 20 mg/ml, 1 ml amp for im, iv or sc use TO Antispasmodics Antispasmodic 20 6 AMPLE Analgesic/Anti-inflam- Ibuprofen 400 mg tablet SO NSAID 1,000 200 matory Analgesic/Anti-inflam- Ibuprofen 600 mg tablet TO NSAID 600 200 matory Analgesic/Anti-inflam- Indomethacin 25 mg tablet TO NSAID 100 x matory Analgesic/Anti-inflam- Indomethacin 75 mg Sustained Release capsule TO NSAID 100 x matory Insulin Human Isophane 100 U/ml Isophane suspension,10 ml vial TO Insulin Diabetes 5 2 Insulin Regular 100 U/ml / 10 ml vial TO Insulin Diabetes 5 2 Ipatropium bromide Nebulizer sol 0.025% 2ml unit dose vial TO Bronchodilator Anti-Asthmatic 6 6 Isosorbide Dinitrate 10 mg Tablet TO Nitrate Vasodilator 100 x Kenacomb nystatin,n'mycin, gramicidin, tr'cinilone cream TO Combination Steroid/Anti-infective 20 x Analgesic/Anti-Inflam- Ketorolac Tromethamine 30mg/ml amp. FOR IV ONLY TO NSAID 20 10 matory 91  DRUG FORMULARY - Figure 4-1 Level A&B Level C&D Generic Dosage Order Class Use Minimum Qty Minimum Qty Ketotifen hydrogen fumarate 1 mg tablet TO Mast Cell Stabilizer Anti-asthmatic 300 x KY Jelly 5 gm tube SO Other Lubricant 12 10 Lactated Ringers 1000 ml for infusion TO Nutritional products Replacement fluid IV 30 10 Lactulose 10 grams/15ml, 200 ml bottle TO Miscellaneous Laxatives 6 4 Lidocaine HCl 1% solution, 20 ml multi dose vial TO Anesthetics Anesthetic (local) 10 2 Lidocaine HCl 10% solution, 80gmspray bottle TO Anesthetic Anesthetic 2 1 Lidocaine HCl 2% jelly, 20 gm tube TO Other Anesthetic 6 2 Lidocaine HCl 2% solution, 20 ml multi dose vial TO Anesthetics Anesthetic (local) 10 2 Lidocaine HCl Oral viscous 2%, 122 ml bottle TO Anesthetic Anesthetic 6 1 Lip Balm Applicator tubes SO Other Miscellaneous 30 12 Loperamide HCl 2 mg capsule SO Antidiarrheal Antidiarrheal 500 200 Lorazepam 1mg Tabs TO Psychotropic Anxiolytic/Sedative 10 x Maalox Suspension 200 ml bottle SO Antacid Antacid 50 20 Mannitol 20 % solution, 500 ml bag for iv infusion TO Cardiovascular Diuretic (Osmotic) 5 2 Mebendazole 100 mg tablet (chewable) TO Anthelmintic Anti-parasitic 30 20 Methocarbamol 500 mg tablet TO Muscle Relaxants Skeletal Muscle Relaxant 1,000 200 Metoclopramide HCl 10 mg tablet TO Anti-emetic Anti-emetic 200 30 Metoclopramide HCl 5 mg / ml injection TO Anti-emetic Anti-emetic 20 6 Miconazole Nitrate 2% powder, 20 gm container SO Anti-infective Anti-fungal 10 x Midazolam 15mg/3ml Inj. TO Psychotropic Anxiolytic/Sedative 10 x Morphine Sulfate 15mg/ml Inj. TO Narcotic Analgesic 10 x Multi sticks Reagent Urine test Urine test strip for multiple agents SO Miscellaneous Diagnostic agents 200 100 Analgesic/Anti-inflam Naproxen 250 mg tablet TO NSAID 300 x matory 92  DRUG FORMULARY - Figure 4-1 Level A&B Level C&D Generic Dosage Order Class Use Minimum Qty Minimum Qty Nitrous Oxide/Oxygen 50/50 mixture in miniature cylinder TO Analgesic Analgesic 6 3 Oral Rehydration salts 14 gm sachet SO Electrolyte/mineral Rehydration 50 10 Otosporin polymixin, n'mycin, hydrocortisone 5 ml BT SO Otic Preparation Steroid/anti-infective 20 6 Oxybuprocaine HCl 0.4% ophthalmic solution, 10 ml dropper BT SO Ophthalmic Anesthetic 10 5 Oxymetazoline HCl 0.05% solution, 10 ml nasal spray SO Otic Preparation Decongestant 40 20 Penicillin VK 600 mg tablet TO Antibiotic Antibiotic 200 100 Petrolatum, white ointment, 30 gm tube SO Lubricant Emollient 20 10 Phenazopyridine HCl 100 mg tablet TO Genitourinary Anesthetic (Urinary) 120 60 Pilocarpine HCl 2% ophthalmic solution, 15 ml dropper bottle TO Ophthalmic Meiotic 5 2 Potassium Chloride 40 mEq ampule, 20 ml vial for iv infusion TO Electrolyte/Mineral Hypokalemia 5 x Povidine Iodine 10% solution, 120 ml bottle (douche) SO Anti-infective Cleanser 10 10 Prednisone 5mg tablet TO Anti-inflammatory Steroid 100 x Prefrin-A 15 ml dropper TO Ophthalmic Decongestant 20 10 Pseudoephedrine HCl 120 mg sustained release tablet SO Decongestant Decongestant 500 300 Psyllium 100 gm bottle TO Laxatives Laxative 20 x Ranitidine 150 mg tablet TO H2 Blocker H2 blocker 600 100 Ranitidine 25 mg/ml, 2ml ampule for iv or im use TO Peptic Ulcer drugs H2 blocker 6 x Retaplase 10 Million Units per vial (2 vials per kit) TO Thrombolytic Anti-thrombus 2 x Salicylic Acid /Lactic Acid Topical Solution 10ml bottle. SO Other Keratolytic 6 6 Silver Nitrate applicators TO Other Keratolytic 50 20 Sodium chloride 0.9% eye drops, 15 ml dispenser SO Ophthalmic Miscellaneous 20 10 Sodium chloride 0.9% nasal spray, SO Nasal Preparation Miscellaneous 20 10 Sodium chloride 10 or 20 ml ampule for iv or sc use SO Electrolyte Diluent 20 20 93  DRUG FORMULARY - Figure 4-1 Level A&B Level C&D Generic Dosage Order Class Use Minimum Qty Minimum Qty Sodium chloride 1000 ml 0.9% solution TO Electrolyte/Mineral Fluid replacement 30 15 Sodium sulfacetamide 15% ophthalmic solution, 15 ml dropper TO Ophthalmic Anti-infective 20 10 Tears naturale ophthalmic solution, 15 ml dispenser SO Ophthalmic Miscellaneous 25 15 Tetanus immune globulin 250 units/syringe for im use TO Immune serum Tetanus passive immunity 5 5 Tetanus Toxoid 0.5 ml dose for im injection SO Vaccine Tetanus Td Prophylaxis 20 10 Throat Lozenges As directed SO Miscellaneous Miscellaneous 1,000 500 Topical Nasal solution non-narcotic solution SO Nasal Preparation Anesthetic 5 x Triamcinolone acetonide 0.1% oral paste, 10 gm tube TO Corticosteroid Steroid 20 10 Triamcinolone acetonide 40 mg/ml, 1 ml vial for im use only TO Corticosteroid Steroid 4 x Water for injection 10 ml ampule SO Unclassified Diluent 20 20 Note: SO = Standing Order TO = Telephone Order 94 (Figure 4-2) ACLS Drug List Qty. Name of Drug 1st week 2nd week 3rd week 4th week Exp Date Remarks 5 vials Adenosine 6 mg. Inj. Vial 3 amps Amiodarone 150 mg. / 3mls 10 tabs Aspirin 325 mgm tab 1 Flumazenil 5mg./ 5mls 4 Atropine SO4 1MG. Abboject 1 Benadryl 50mgm vial 1 Calcium Chloride 10% injection 1 Dextrose 50% Abboject 1 5% Dextrose injection. 500 mls 2 Dopamine 400 mg. Vial 3 EPI 1: 10,000(.1mg/10ml) Abboject 2 EPI 1: 1,000 (1mg/ml ) amp. 2 Heparin 5,000 U/ml 1 Lasix 20mg / 2ml ampules 3 Lidocaine 2% (20 mgm / 5mls) Abboject 1 Lidocaine 20% (200mg / 1mls) Abboject 2 Magnesium S04 50% 1 g 2 Narcan Ampules 1 Nitroglycerin 50mg. (5mg. / ml.) 1 bottle Nitrostat 0.4 mg. tabs 1 Potassium Chloride 10 ml ampule 2 Plasil 10mg / 2mls 2 Sodium Bicarbonate 50mg Abboject 4 Sodium Chloride 0.9% inj.10mls 1 Ventolin Inhaler 95 1 bottle Ventolin solution 4 Water for Injection - 10mls Retaplase to be taken separately Narcotics to be taken separately Nurse Signature: Badge Number: (Figure 4-3) Standing Orders Guidelines for Nurses In the event nurses are authorized to administer and dispense drugs in the absence of a physician or pharmacist, clear written administration and dispensing guidelines in line with MOH regulations must be in place. This could be in the form of a “standing order” or a “routine order” from the responsible physician. Note: The guidelines listed below are to be used as a reference to assist you in developing your own standing orders/ protocols. Standing Orders (SO) Refer to Physician Treatment/Education Refer if headache is associated with any of the following: high blood Refer to facility’s Nursing Protocol. pressure, high fever, nausea, vom iting, Always take patient’s blood pressure. history of injury and acute severe headache. Headache Headache of recent onset with normal vital signs and no other Refer if persistent headache. complaints, give Panadol per schedule dosage. Headache associated with sore throat or common cold, give Refer if history of head trauma. Panadol per schedule dosage. Headache with dizziness, give Panadol per schedule dosage and 1 Dramamine requires a physician’s tablet of Dramamine three times a day (tid). order. Chest Pain Follow facility’s Nursing Protocol if chest pain is not associated with the typical symptoms of heartburn and/or indigestion. Notify the physician. ASA 300mg PO X 1 Nitroglycerine SL 0.4 mg tab, repeat every 5 min X 3 Start IV to keep vein open. ALWAYS REFER ALL CASES Give Morphine sulfate per physician’s order. IV fluids and morphine require a Place patient in semi-fowler’s position. physician’s order. Start oxygen 6 liters per minute. Place on Life Pak monitor, if available. Twelve lead EKG, if available. Take vital signs as often as necessary and document. Transport by the quickest method to the nearest medical facility. Accompany patient during transportation. Refer to facility’s Nursing Protocol. Apply analgesic balm. Backache Mild or recent onset without any associated complaints, give Refer all other cases. Panadol per schedule dosage. If no improvement in two days, refer to physician. 96  Standing Orders (SO) Refer to Physician Treatment/Education Common cold associated with any of the following: Temperature over 38 Mild cold without any associated complaints (i.e., fever, produc tive Celsius (104.4 Fahrenheit), loose Common Cold cough, etc.), give Panadol per schedule dosage. productive cough with purulent sputum, earache, sinus pain or rhinorrhea. Give Isoptocetamide eye drops every 4 hours. Check Refer severe cases. G6PD status. Conjunctivitis (mild) Give erythromycin eye ointment to be applied at bedtime. If no Erythromycin and Isoptocetamide require improvement in 48 hours, refer to physician. a physician’s order. Refer all cases. Patch the affected eye with an eye pad. If Flash Burn of Eye Analgesics require a physician’s indicated, apply analgesic. order. Check vision on eye chart and record prior to eye examination. If simple foreign body, apply Novesine 0.4%, 2 drops; remove foreign body with sterile cotton bud. Refer all cases Stat. Foreign Body in Eye Use normal saline as eyewash after removal. Novesine requires a physician’s Other foreign objects: perform first aid treatment only, apply Novesine order. 0.4%, 2 drops, cover eye with eye patch. Reevaluate in two hours. If no evidence of acute irritation, recommend cold compress 3 times a day. Itching Sensation in Prefrin-A requires a physician’s Give Prefrin-A 1-2 drops, every 6 hours. Eyes order. Advise patient to return If no improvement in 48 hours, refer to physician. Apply warm, moist compressed for 15 minutes four times a day (qid). Give Isoptocetamide eye drops every four hours and Erythromy cin eye ointment at bedtime. Sties Check G6PD status. Advise patient to return if condition worsens or persists longer than 3 days. Give first aid treatment. Cover both eyes with normal saline pads. Trauma to Eyes Refer all cases. Immobilize impaled object. Check tetanus status. Refer if foreign body appears impact ed If foreign body (such as fly) appears easy to remove, irrigate with Foreign Body in Ear (such as a bean or small stone) or is warm normal saline solution using bulb syringe. difficult to remove by irrigation. Other Eye Complaints Refer all cases. Apply Otosporin ear drops every (q) 6 hours. Never plug ears with cotton. Ear Discharge, Ear Pain Refer all cases. Give Panadol per schedule dosage for pain. Give Auralgan ear drops for earache. Refer if not previously diagnosed. Refer if If this is the first instance of allergy, give antihistamine and refer to a Allergic Rhinitis no improvement after taking medication. physician. 97  Standing Orders (SO) Refer to Physician Treatment/Education Examine nasal passages. Keep patient’s head erect, pinch side of nose against septum for five Epistaxis (minor) (5) minutes. May apply vaseline gauze nasal packing if necessary. Check and record blood pressure & pulse prior to referral. Mild Throat Irritation with Normal Tempera- Recommend warm saline gargles or mouth spray. ture Mild Sore Throat with Give Panadol per schedule dosage. Temperature of 38 °C Recommend warm saline gargles or mouth spray. Tonsillitis with Temper- Recommend warm saline gargles or mouth spray. Give Refer all cases. ature of 38 °C Panadol per schedule dosage. Refer if persistent or recurrent cough. Give Romilar expectorant, 2 teaspoon (tsp) every 4-6 hours, as Cough Associated with Refer if cough is associated with any of needed. Common Cold the following: weight loss, ele vated See nursing protocol for upper respiratory infection. temperature, purulent sputum or hemoptysis. Give liquid Maalox (antacid) 2 teaspoon every 4 hours or Maalox tablets, 2 tablets every 4 hours. Refer recurrent cases. Heartburn/ Indiges- tion Provide dietary advice: reduce spices, fried foods, etc. Refer if chest pain remains a possi bility. Nothing by mouth (NPO) till evaluated. Monitor vital signs. Vomiting Refer all cases. Give anti-emetic for severe cases. Close observation. Refer in sickle cell disease and if severe cases associated with any of Abdominal Pain Refer to facility’s Nursing Protocol. the following: nausea, vomiting, fever, tenderness and abdominal guarding. Refer to facility’s Nursing Protocol. Refer severe diarrhea. Refer all severe cases associated with Give Imodium (Loperamide HCL), 2 capsules (4 mg) initially, then 1 Diarrhea any of the following: nausea, vomit ing, capsule every bowel movement; maximum of 8 capsules (16 mg) in 24 fever, blood in stool and dehy dration. hours. Give milk of magnesia 2 tablespoons (tbsp) (2 oz) or Dulcolax 1-2 Refer constipation associated with tablets at bed time. Constipation abdominal pain, nausea and/or Advise patient to increase fluid intake, fruit and vegetables in diet vomiting. and moderate exercise. Give Anusol suppository and advise sits baths, 20-25 minutes daily. Hemorrhoids Refer all cases. Repeat process every day until relief is obtained. Rectal Bleeding Refer all cases. Burning and Frequency of Refer to facility’s Nursing Protocol on Urinary Tract Infection. Refer all cases. Urination 98  Standing Orders (SO) Refer to Physician Treatment/Education Pain Suggestive of Refer all cases. Renal colic Urethral Discharge Refer to facility’s Nursing Protocol on Urinary Tract Infection. Refer all cases. Gross Hematuria Refer all cases. Acute Scrotal Refer all cases. Swelling and Pain Refer if more than two days dura Apply analgesic balm and give Panadol per schedule dosage. Generalized Musculo- tion. If associated with common cold or sore throat, treat as common cold skeletal Ache or Pain Refer if temperature is elevated over 38 or sore throat. °C. Localized with no redness or swelling, give Panadol per schedule Refer if associated with any of the dosage and analgesic balm for local application. following: redness, swelling, elevat ed Joint Pains Advice hot compresses or sitting in hot bath. temperature. If associated with common cold or sore throat, treat as common cold Refer if condition worsens or per or sore throat. sists. Apply Vaseline ointment. Give Dry Skin lanolin, ½ ounce (oz). Dry Lips Give Vaseline ointment. Apply calamine lotion locally. Heat Rash Advice patient to keep skin dry, bathe only once a day, avoid bathing in hot water, and wear lightweight clothing. Advise warm water or saline compresses. Give bacitracin ointment four times a day (qid) if lesion not ready Refer if boil is on nose or upper lip. for incision and discharge (I&D). Boils Give Panadol to relieve pain per schedule dosage. Refer if signs of cellulitis. Refer if multiple boils, recurrent or Change dressing daily. with abscess formation. Refer if acute with maceration or In chronic phase with scaling, give Daktarin powder or Canesten cream infected. Athlete’s Foot and advise good hygiene. Medication requires physician’s order. For removal of corns apply 1 drop of Collomack solution in the Corns morning and evening. After a few days of treatment, soak foot in hot Refer if diabetes or infection. bath to loosen the corn for removal. Apply 1 ounce of Kwell shampoo and rub vigorously for 4 min utes, Kwell shampoo requires a physi Lice (Head) then wet hair with warm water and rinse thoroughly. Repeat cian’s order. treatment in one week. Give Kwell cream or lotion. Apply a thin layer to hairy infected areas and adjacent areas. Leave on overnight (8-12 hours) then wash off. Kwell shampoo requires a physi Lice (Body) Repeat application in one week. cian’s order. Discuss hygiene/contagion. Family members may need treatment Apply povidone-iodine 10% (clonidine) or 70% alcohol to the Herpes Simplex Requires a physician’s order. affected area. 99  Standing Orders (SO) Refer to Physician Treatment/Education Report all on/off-the-job injuries as per your organization guidelines. Evaluate need for tetanus immunization and immunize as Injuries indicated. Refer all cases. Initiate immediate first aid treatment for all injuries. Elevate affected part. Contusion(s) Apply cold compresses to diminish edema. Refer if contusion(s) severe. Apply ace bandage as appropriate. Elevate and rest affected part. Apply cold compresses or ice bag for first 12 to 36 hours. Give Refer if severe, gross swelling, frac Sprains Panadol for pain per schedule dosage. ture and/or loss of function. Apply ace bandage. Apply heat after 36 hours. Cleanse with soap and water or saline. Irrigate thoroughly. Abrasions and Superfi- May apply antiseptic ointment or Vaseline dressing. cial Punctures Evaluate need for tetanus toxoid immunization and immunize as indicated. If minor, such as nail wound: Clean and apply dry, sterile dressing. Evaluate need for tetanus toxoid immunization and immunize as Refer if patient returns with persis tent Lacerations (if Minor) indicated. pain or signs of infection. Advise patient to return if pain persists or signs of infection appear. Refer to burns treatment protocol. Remove clothing. Refer if more extensive or severe Flush vigorously with several liters of water; shower if possible. Do not burns. Chemical Burns waste time looking for s specific neutralizing agent. Refer if burns involving face, hands, (except of eyes) Treat as thermal burns. soles of feet or perineum. Monitor breathing closely for signs of pharyngeal swelling and airway Refer if all circumferential burns. occlusion. Refer if any signs of sepsis. Obtain name of chemical and MSDS instructions. Refer to minor burn treatment protocol. Wash affected area gently with detergent soap (povidone-iodine detergent is recommended). Refer if more extensive or severe Rinse thoroughly. burns. Minor Burns (first degree Do not apply ice. Ice has the theoretical disadvantage of Refer if burns involving face, hands, or small second degree vasoconstriction and possible ischemia of tissue in and adjacent to the soles of feet or perineum. burns) burn. Refer if all circumferential burns. Apply bacitracin dressing and change every 48 hours. Give Refer if any signs of sepsis. Panadol per schedule dosage. Evaluate need for tetanus toxoid immunization and immunize as indicated. 10 (Figure 4-4) Examination and Treatment Protocol (TP) for Nurses Backache Body Parts Involved: Vertebrae, Spine Name: Badge No.: MR No.: Date: Time in: History and Physical Examination 1. Is onset of pain sudden  Yes  No History trauma  Yes  No Is pain referred  Yes  No History of renal calculus  Yes  No Recent heavy lifting  Yes  No Movement restriction  Yes  No History of spondylosis  Yes  No History of disc prolapsed  Yes  No History of rheumatoid  Yes  No History of arthritis  Yes  No 2. Is pain Mechanical: Made worse by prolonged sitting or standing, relieved by movement or inflammatory agent or prolonged early morning stiffness and is relieved by exercise 3. Are there any sensory or motor symptoms?  Yes  No If yes, describe: 4. Any change in bowel or bladder function?  Yes  No If yes, list: 5. Vital Signs: Temperature: BP: Pulse: Respiration: 6. Urinalysis:  Yes  No If yes, list result: Guidelines for Treating Nurse 1. Prior history of long standing backache and normally on prescribed medication, this should be given to the patient if available (with no other presenting symptoms) otherwise: In all cases of persistent backache the patient should be seen or referred to a clinician with the following instructions: Used of proper body mechanics when moving or lifting heavy objects. Bend at the knees and hips when lifting and use the feet to pivot. Keeping the spine perfectly straight, do not bend or twist the back. Keep loads close to the body when lifting. Avoid aggressive exercises when in pain. Note: Give patient education guidelines for safe lifting techniques. 2. If back pain is work-related, prepare and submit QI-30. 10 (Figure 4-4) Examination and Treatment Protocol (TP) for Nurses Headache Body Parts Involved: Neurological System Name: Badge No.: MR No.: Date: Time in: History and Physical Examination 1. History of recurrent headache  Yes  No Migraine  Yes  No 2. Trauma recent (within 24 hours)  Yes  No Within last 7 days  Yes  No 3. High velocity  Yes  No Blunt injury  Yes  No 4. Sudden onset  Yes  No Loss of consciousness  Yes  No 5. Fully alert and orientated  Yes  No Photophobia  Yes  No 6. Pyrexia  Yes  No Neck Rigidity  Yes  No 7. General Malaise  Yes  No Drowsiness  Yes  No 8. Nausea and vomiting  Yes  No Impaired vision  Yes  No 9. Sinusitis  Yes  No Flu like symptoms  Yes  No 10. Earache  Yes  No 11. Hypertension  Yes  No Hypotension  Yes  No 12. Epilepsy  Yes  No 13. Psychiatric illness  Yes  No Stress  Yes  No 14. History of alcohol abuse  Yes  No Drug or solvent abuse  Yes  No 15. Severe pain  Yes  No Localized pain  Yes  No 16. Trigeminal neuralgia  Yes  No Guidelines for Treating Nurse In the event of sudden onset of severe headache with or without neurological symptoms, the patient must be seen by a clinician as soon as possible. 1. Where history of head trauma, baseline observations, such as: temperature, pulse, blood pressure, respirations, and pulse oximeter must be performed and recorded. 2. If there is any loss of consciousness or disturbance of conscious level, ensure that the patient’s airway is protected at all times. 3. A Glasgow coma scale and neurological status must be obtained and recorded. 4. If a patient presents with neck rigidity, photophobia, nausea, vomiting, and/or dizziness, he must be seen by a clinician and referred to hospital as soon as possible. 5. If a patient presents with hypotension or hypertension, with no prior history, he must be seen by a clinician as soon as possible. 6. Patients with prior history of migraine or longstanding headache, normally on prescribed medication; the patient shall be asked when medications were last consumed/taken. 7. A patient presenting with associated common cold or influenza, treat as instructed by the clinician. 8. Prolonged history of recurrent headache, with no prior investigations should always be referred to a clinician for evaluation. 9. If a patient presents with any neurological disturbance he shall immediately be examined by a clinician. 10