Microsoft word - standing medication orders - student.doc

STANDING MEDICATION ORDERS FOR THE MINNESOTA ACADEMIES
Parents and Guardians,

The following is a copy of our standing orders for over-the-counter medications. These
medications are given as needed to treat symptoms of illness or aches. These orders have been
reviewed and signed be a local physician (Dr. D.A.McIntyre M.D.). Please read through and sign at
the end if you give permission for these medications to be given to your child. You may cross out
and initial any medications that you prefer not be given. We may not give any over-the-counter
medications without this form. Thank you.

The Health Clinic Nurses
ORAL MEDICATIONS

1. Acetaminophen 500mg: Children 12 years of age and older: For headache, sore throat,
pain, or fever. One-two caplets every 4-6 hours prn 2. Acetaminophen 325 mg: For relief of headache, sore throat, pain, or fever. Children 12
years of age and older: One-two tablets every 4-6 hours prn. Children (6-11): ½ to 1
tablet every 4-6 hours prn
3. Children’s Liquid Tylenol (160mg/5ml): For relief of headache, sore throat, pain,
or fever. Children (6-8) 2 tsp. every 4 hours prn. Children (9-10) 2 ½ tsp. Every 4 hours
prn. Children (11) 3 tsp. every four hours prn.
4. Acetaminophen Jr. Chewable Tablets 160mg: Every four hours as needed for headache,
sore throat, pain or fever. Children (6-8) 2 tablets, Children (9-10) 2 ½ tablets, Children
(11) 3 tablets, Children (12 years) 4 tablets.
5. Ibuprofen 200mg: Children 12 years of age and older: One to two tablets every 4-6 hours
for pain or menstrual cramps. (Do not exceed 6 tablets in 24 hours) 6. Children’s Ibuprofen 100mg/5ml: For relief of fever, minor aches and pains.
Dosage: Children 6-8years 2 tsp., 9-10 years: 2½ tsp., 11 years: 3 tsp. Dose may be
repeated every 6-8 hours prn.
7. Tussin DM Cough Formula: For relief of coughs and chest congestion. Children 12 years
and older: 2 tsp. every 4 hours prn. Children 6-12 years: 1 tsp. every 4 hours prn.
Children under 6: ½ tsp every 4 hours prn.
8. Sore Throat Spray: For relief of sore mouth, sore throat pain, and canker sores. Children
12 years and older: Spray 5 times on affected area. Children under 12 years: Spray 3
times.
9. Children’s Dimetapp Cold and Allergy: for relief of nasal congestion, sneezing, runny
nose, itchy, watery eyes. Children 12 years and older: 4 tsp. every 4 hours prn, Children 6-
12 years: 2 tsp. every four hours prn.
10. Suphedrine 30mg: For relief of nasal congestion. Children 12 years and older: 2 tablets
every 4-6 hours prn. Children 6-12 years: 1 tablet every 4-6 hours prn.
11. Benadryl 25 mg: For relief of runny nose, sneezing, itching of the nose or throat, and itchy,
watery eyes. Children 12 years and older: 1-2 tablets every 4-6 hours prn. Children 6-12
years: 1 tablet every 4-6 hours prn.
12. Loperamide Hydrochloride Tablets 2mg (Anti-Diarrheal): For relief of symptoms of
diarrhea. Children 12 years and older: Take 2 tablets after the first loose bowel movement
and 1 tablet after each subsequent loose bowel movement. Children 6-12 years: Take 1
tablet after the first loose bowel movement and ½ tablet after each subsequent loose bowel
movement.
13. Antacid Tablets 500mg (Tums): For relief of acid ingestion and heartburn. Chew 2-4
TOPICAL MEDICATIONS

1. Triple Antibiotic Ointment (bacitracin): To help prevent infection in minor cuts, scrapes,
2. Hydrocortisone 1% Cream: For relief of itching associated with rashes and inflammation.
3. Diphenhydramine Hydrochloride 2% (Benadryl Cream): Used for relief of itching from
insect bites or rashes from plants, such as poison ivy. Apply to affected area 3-4 times a day.
Consult a physician for children under 12 years of age.
4. Ben-Gay: For relief of muscle aches. Apply generously and gently massage until Ben-Gay
5. Vicks VaporRub: For relief of nasal congestion and coughing due to colds.
6. Tolnaftate Cream USP, 1%: For relief of symptoms related to ringworm or athlete’s foot.
Apply thin layer of cream over affected area BID. 7. Eye wash (sterile isotonic solution) : For cleansing of irritated eyes and/or removal of loose
foreign material. Apply drops to eyes as needed.
1. Warm Packs or Soaks for infection.
2. Cold Packs for sprains, bruises, or other traumatic injuries.
3. Povidone Iodine Scrub Solution as needed for cleansing of wounds.
4. Band-aid Hurt-Free Antiseptic Wash for cleansing of wounds as needed.
5. Aloe Vera Gel or Lotion for sunburn.
6. Cough Drops for cough.
7. Carmex for cold sores, fever blisters, and chapped lips.
8. Anbesol for cold sores/canker sores.
I consent to the use of these over-the counter medications for my child. They will only be
administered as needed and as ordered. I have crossed out any medications that I do not
want my child to have.
Student Name: _____________________

Parent Signature _____________________ Date: _____________

Source: http://www.msab.state.mn.us/Forms/Student%20Forms/STANDING%20MEDICATION%20ORDERS.pdf