Policy Manual sample

MDT Home Health Care Agency, Inc. 3 STANDING ORDERS FOR TREATMENT OF ALLERGIC/ANAPHYLACTIC REACTIONS: PATIENT NAME: ___________________________________________________ DATE: _____________________ PATIENT #: _________________________ DOB: _______________________ WT. (kg):_____________________ ALLERGIES:______________________________________________________ A. URTICARIAL/ALLERGIC REACTION (HIVES, ITCHING, RASH): 1) Discontinue infusion immediately. 2) Administer Benadryl _____________________________________________ Dose/Route/Frequency (1.25 mg/kg with max 50mg) 3) Monitor vital signs every 15 minutes x 1 hour or as indicated by patient symptoms. 4) Notify physician for further orders. B: ANAPHYLACTIC REACTION: 1) Discontinue infusion. Initiate new bag of Normal Saline with new unfiltered tubing at a rate of ______________ ml/hr. 2) Administer Epinephrine 1:1000 ___________________________________ Dose/Route/Frequency (0.01 ml/kg to max 0.3-0.5 ml) 3) Notify physician for further orders at _____________________________ 4) Notify Emergency Medical Service. PHYSICIAN SIGNATURE: ________________________________________ DATE: _________________________________________________________ NURSE SIGNATURE: ____________________________________________ DATE: _________________________________________________________