Overcountermeds

Patient Name: D.O.B. Date Of Visit: Allergies: Physician: PHYSICIANS ORDERS
FOR OVER THE COUNTER MEDICATIONS
√ for permission to administer to patient upon communication of identified symptoms and request for PRN and medication. Medications
Indications (Dosage, Signs, & Symptoms)
Signs & Symptoms: For pain or fever
Dosage: (325 mg) 1 tab every 4-6 hours for mild pain; 2 tabs for moderate pain; not to exceed 8 tabs in a 24 hour
period.
Signs & Symptoms: For musculoskeletal pain or fever.
Dosage: (200 mg) 1 tab every 4-6 hours for mild pain; 2 tabs for moderate pain; not to exceed 8 tabs in a 24-hour
period.
Signs & Symptoms: For menstrual cramping.
Dosage: (200 mg) 1 tab every 4-6 hours for mild pain; 2 tabs for moderate pain; not to exceed 8 tabs in a 24-hour
period.
Signs & Symptoms: For nasal/sinus congestion.
Dosage: (60 mg) 1 tab every 6 hours; not exceed 3 tabs in a 24-hour period.,
Signs & Symptoms: For allergy symptoms.
Dosage: (25 mg) 1 tab every 4-6 hours for mild symptoms; 2 tabs for moderate symptoms; not to exceed 8 tabs in
a 24-hour period.
Signs & Symptoms: For gastric acid.
Dosage: (350 mg) 2 tabs every 4 hours; not to exceed 8 tabs in a 24-hour period.
Signs & Symptoms: For gastric acidity or heartburn.
Dosage: (25 mg) 2 tsp. with 4 oz. of water for mild symptoms; 4 for moderate symptoms; not to exceed 4 times in
a 24-hour period.
Signs & Symptoms: For diarrhea & loose stools.
Dosage: (1 mg/5 ml) 1 tbsp. initially for diarrhea; then 2 tsp. for additional loose stools up to 4 times in a 24-
hour period.
Signs & Symptoms: To induce vomiting in the event of poison ingestion, after consultation with Ask A-Nurse.
Dosage: 1 tbsp. followed by a minimum of 8 ounces of water.
Signs & Symptoms: For constipation.
Dosage: (30 ml) 2 tbsp. at bedtime; may repeat up to 1 time in a 24-hour period.
Signs & Symptoms: For minor threat irritation or cough.
Dosage: 1 lozenge slowly dissolved orally; may repeat every hour during waking hours.
Signs & Symptoms: For minor throat irritation.
Dosage: Spray 5 times directly into throat; may repeat every 2 hours.
Signs & Symptoms: Minor sprains, sores, or skin inflamation.
Dosage: Dissolve 2 cupfuls per gallon of warm water; soak or apply solution soaked dressing 30 minutes up to 3
times a day.
Signs & Symptoms: For itching, burning, scaling, & discomfort of athlete’s foot, jock-itch, or wring-worm.
Dosage: Apply thin layer 2 times daily after thorough cleaning and drying.
Signs & Symptoms: For itching, burning, scaling, & discomfort of athlete’s foot, jock-itch, or wring-worm.
Dosage: Apply thin layer 2 times daily after thorough cleaning and drying.
Signs & Symptoms: Nasal congestion, cough, & minor muscle aches.
Dosage: Apply topically to chest & throat (externally) & areas of muscle soreness 3 times daily as needed.
Medications
Indications (Dosage, Signs, & Symptoms)
Signs & Symptoms: For prevention & treatment of nausea/dizziness associated with motion.
Dosage: (50 mg) 1 tab prior to travel & every 4-6 hours as needed for motion sickness.
Signs & Symptoms: Head lice.
Dosage: Saturate hair & scalp with Nix & leave on for 10 minutes, rinse. Re-apply in 7 days if nits reappear.
Signs & Symptoms: For dietary supplement.
Dosage: Give (1000 mg) 1 tab daily.
Signs & Symptoms: For dietary supplement.
Dosage: Give 1 tab daily.
Signs & Symptoms: For treatment for minor cuts, scrapes, & burns.
Dosage: Apply small amount topically to wound (after thorough cleaning); not to exceed 3 times in a 24-hour
Signs & Symptoms: For itching.
Dosage: Apply small amount to affected area; not to exceed 4 times in a 24-hour period.
Signs & Symptoms: For itching related to poison oak/ivy or sumac.
Dosage: Apply small amount to affected area; not to exceed 4 times in a 24-hour period.
Signs & Symptoms: For cleaning of minor cuts & abrasions.
Dosage: Apply per package instructions.
Signs & Symptoms: For pain, discomfort, or itching related to abrasions, sunburn, dermatitis, or psoriasis.
Dosage: Apply to affected area up to 4 times in a 24-hour period.
Signs & Symptoms: For sun sensitivity & to prevent burns due to sun exposure.
Dosage: Apply liberally to exposed areas of the skin 1 hour prior to sun exposure.
Signs & Symptoms: For discomfort of water clogged ears. Do not use if ear drainage, discharge, or pain are
present - see physician.
Dosage: Administer 4-5 drops in each ear 1 time.
Signs & Symptoms: For potential exposure to insects.
Dosage: Hold container 6-8" from surface-apply to skin/clothing avoiding eyes & mucus membranes use prior to
outings; may reapply every 2-3 hours as needed.
Signs & Symptoms: For potential exposure to insects.
Dosage: Apply to skin/clothing avoiding eyes & mucus membranes use prior to outings; repeat as needed.
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I hereby give my consent for Krista Foster Homes to provide treatment for the listed signs and symptoms identifiedwith the medication above at the frequency and amount specified. By signing this form, I am authorizingmedication as necessary for the client whose name appears at the top of this form.

Source: http://www.kristafosterhomes.org/1/new%20Forms/overcountermeds_KRISTA.pdf