Protocol PRN Orders for Timothy L.

Heston, DO and Vintage Medical Associates Providers Admission Labs: o Draw Comp, CBC, TSH, UA-C & S, HgbA1C for Diabetics (if not completed in past 6 months) Lab: o SPECIFIC LABS FOR MEDS NEEDING LAB MONITORING NEED TO BE ADDED TO THIS!!!! o Diuretic Chem basic every 6 months o Digoxin level every 6 months o Synthroid TSH level every year o Theophylline level every 6 months o All new admissions taking Coumadin are to have a PT/INR next lab day; then monthly unless otherwise ordered o Valporic acid (Depakote) level every 6 months o Dilantin level every 6 months o Tegretal level every 6 months o Phenobarbital level every 6 months o Hgb AIC every 6 months for diabetics o PSA annually for male greater than 50 and less than 75 years old o Cholesterol lowering medications - fasting lipids every year and CMP every 6 months Temp Elevation: o Acetaminophen 650mg every 4 hours PRN temp >101.5 rectally, or >99.5 axillary; liquid, tablet, or suppository form may be used o Temperature >100 (axillary)/101 (oral)/102 (rectally) notify physician for 24 hrs (for physician call) Discomfort (Pain) o Acetaminophen 650mg every 4 hours PRN mild to moderate discomfort, liquid, tablets or suppository may be used. 6 doses in 24= adequate trial, call if pain persists o Saline gargle (1/2 tsp. Salt in 8oz. Water) PRN for sore or irritated throat for 24 hours o Cold pack for 20 min. out of 60 for mild local discomfort or swelling for 24 hours o Robitussin DM 10cc po every 4 hours PRN cough, use diabetic cough syrup if indicated o May use natural tears TID PRN dry eyes o Non-injury falls fax to office for notification; if injury occurs notify o Notify physician if ineffective or severe pain (call for physician) Constipation (without abdominal pain and bowel sounds are present) o Milk of Magnesia 30cc P.O. BID PRN if no stool for 3 days o Bisacodyl suppository 1 rectally PRN if no stool for 3 days if MOM is ineffective o Fleets or soapsuds enema rectally PRN if MOM or suppository not effective o Notify physician if constipation persists; pain present or develops; or bowel sounds absent (for physician call) Chest Pain o With history of Coronary Artery Disease or previous Myocardial Infection NTG 0.4mg SL q 5 min PRN persistent pain up to 3 doses always call o With history of cough over recent days Diarrhea o Licensed nurse to perform abdominal and rectal assessment, if no distention or hard stool in rectal vault, then resident may receive: o Clear liquid diet for 24 hours, may advance diet as tolerated o Immodium 2mg., 2 tabs now and one after each loose stool up to 8 tabs for 24 hours

Notify physician if stools contain blood; continue >24 hours; or more than 6 stools in 24 hours _______________(Physician Initials)

Catheter Care o Replace indwelling foley catheter every 4 weeks and PRN o Change collections bag every 4 weeks and PRN o Obtain UA and C&S, if indicated, for new ones S/S UTI: dysuria, frequency, burning, hematuria, cloudy urine, elevated temp, increased incontinence, retention or confusion. May straight cath for urine specimen if unable to obtain otherwise. CALL for all urinary retention. Wound/Skin Care Implement appropriate facility skin/wound management protocols o Petroleum jelly to lips topically PRN chapped or irritated lips until healed. Notify physician if persists more than 10 days o Use Telfa with or without TAO and/or Lyofoam on skin tears. Do not use Douderm o Eucerin Cream or equivalent to dry areas BID o MVI daily 14 o Zinc 220mgs BID x 14d o Vit C 500mg BID o Peg sites maybe cleaned w/soap & water BID and TAO applied Diet o All residents may have salt substitute unless a specific order by the primary care provider o Residents with poor intake <75%, may have fortified foods, like super cereal, power potatoes or super pudding o Facility nutritional supplements may be given for weight loss Nausea, Vomiting or Indigestion o Antacid of choice 15cc every 4 hours PRN for gastric upset for 72 hours o Compezine or Phenergan suppository 25mg 1 rectally every 6 hours for nausea/vomiting for 24 hours o Tigan 250mg PO/q 6 hours PRN or 200 mg rectally/q 6 hours PRN for nausea/vomiting for 24 hours o Notify physician if vomiting persists >24 hours, or if resident unable to retain po or rectal medication Respiratory Distress o Oxygen at 2 liters via NC or mask PRN respiratory distress. (if resident is known to have COPD, place flow at 1 liter). Obtain Sao2 when initiating oxygen therapy o Notify physician of all respiratory distress immediately o May use suction PRN Ear Wax o Debrox ear drops, 5 drops in affected ear bid x 4 days PRN earwax unless resident has signs/symptoms of ear infection: pain, fever, and discharge. Irrigate per protocol on 5th day. o May repeat for another 3 days if unable to dislodge cenumen with first irrigation. o Notify physician if second round of drops/irrigation is unsuccessful. Immunizations o May have annual flu vaccine unless has allergies o Pneumonia Vaccine. If hasnt had one given at admission and one in 5 years o May do initial 2 step TB test and then annually Misc. o May D/C any PRN med not used in 30 days o Notify Dr. Heston of residents death, send body to mortuary of resident/family choice. Fax facesheet, recent H&P or progress note and last 3 pages of nurses notes to office with time of death o PT/OT may screen/admit new pts if appropriate

Anusol HC suppository or generic rectally at HS PRN hemorrhoids

(Physician Signature)

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