Download SYMPTOM RESPONSE KIT – Prescription/Order form

SYMPTOM RESPONSE KIT – Prescription/Order form
First Kit
Replacement Kit (pick up old kit)
Name:
Address:
DOB:
OHIN:
Allergies:
Phone:
Date Ordered:
NOTE: Consider any potential risks to storing injectable opioids in the home
Symptom
Pain/Dyspnea
MD initials
Oropharyngeal secretions
Agitation/Nausea
Persistent seizures
Medications
Morphine
Hydromorphone
Hydromorphone
Atropine Sulfate
Haloperidol
Diazepam*
Midazolam*
Midazolam*
Furosemide*
Dexamethasone
Concentration
15 mg/ml (parenteral)
2 mg/ml (parenteral)
10 mg/ml (parenteral)
1% drops
1 drop ~ 0.5 mg
5 mg/ml (parenteral)
5 mg/ml (parenteral)
5 mg/ml (parenteral)
5 mg/ml (parenteral)
10 mg/ml (parenteral)
4 mg/ml (parenteral)
Specific Order
mg sc q4h +
mg sc q1h prn
mg sc q4h +
mg sc q1h prn
mg sc q4h +
mg sc q1h prn
1 drop sublingual q4h prn
If not effective → 2 drops sl q4h prn
1 mg sc q12h + 0.5 mg sc q1h prn
mg per rectum once
mg sc once
1 mg sc q2h + 0.5 mg sc q1h prn
20 mg IM once
mg sc at (times):
Dispense
1 ml amp
1 ml amp
1 ml amp
5 ml bottle
2 x 1 ml amps
3 x 2 ml amps
6 x 1 ml amps
10 x 1 ml amps
3 x 2 ml amps
3 x 5 ml vials
Agitation (for sedation)
Pulmonary edema
Symptom Management
Other:
Other:
*Medications covered only if ordered by MD listed on Palliative Care Facilitated Access list or if expedited request made by calling 1-866-811-9893.
Insert Foley Catheter to straight drainage PRN
Irrigate Foley PRN and change Foley monthly PRN
CONTACT A PHYSICIAN PRIOR TO ADMINISTERING ANY OF THE ABOVE MEDICATIONS
YES
NO
Physician’s name:
Physician’s signature:
Address:
CPSO#
Office phone number:
Pager number:
Fax number:
Secondary phone number:
Alternate physician information Name:
Phone number:
Pager number:
Nurses name:
LOCATION OF SYMPTOM RESPONSE KIT IN HOME:
For information or advice any time of day contact:
Ontario Medical Supply (OMS) (Mon – Sun 0800 – 2000) : 1-800-461-3599 x 5900 After hours pager number: 1-888-290-8226
Queen’s Palliative Care Medicine (Mon – Fri 0800 – 1700): 613-548-2485 After hours: 613-548-3232 (KGH Switchboard)
Palliative Pain & Symptom Management Consultation Service: (Mon – Fri 0830 – 1630): 1-888-547-7744
SE CCAC #15 (Dev. Feb 2012)
Instructions for physicians:
1) Place your initials in the column of the table for any medications you want included in the kit.
2) Complete the order and prescription in the row for each selected medication.
3) Fax this completed form to the CCAC Case Manager responsible for the patient’s care:
CCAC Location
Kingston
Bancroft
Belleville
Selby
Northbrook
Smiths Falls
Brockville
Fax number
613-544-1494
613-332-4873
613-966-0996
613-388-2646
613-336-9104
613-283-0308
613-283-0308
4) Reorder a symptom response kit using a fresh Prescription/Order Form:
 When the expiry date on the outside of the kit passes
 When medications need to be added or changed
When the kit is used for a crisis, the nurse and physician decide whether or not items need to be replaced. Replacements can be obtained at any
pharmacy.
Opioid Conversion Doses (from Cancer Care Ontario)
Drug
Approximate Equivalent Dose (mg)
Parenteral
Oral
Codeine
120
200
Fentanyl
0.1-0.2
n/a
Morphine
10
20-30
Hydromorphone
2
4-6
Oxycodone
n/a
30
Persistent generalized seizures lasting over 5 minutes:
Diazepam 0.2 mg/kg rectally (maximum 20mg)
or
Midazolam 0.2mg/kg subcutaneously (maximum 15mg)
Resource: Cancer Care Ontario Guides to Practice: https://www.cancercare.on.ca/toolbox/symptools/
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2 - 12F Foley Catheters
2 - 14F Foley Catheters
Foley catheter insertion kit
1 Foley night bag
12 – 1cc syringes
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Supplies for All Kits
12 - 3cc syringes
12 – 25g 5/8”needles
12 – 25g 1” needles
4 – 21g 1.5” needles
4 – injection caps
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2 – 23g and 2 – 25g Butterflies
24 - syringe cannulas
50 – alcohol swabs/ 1 roll paper tape
4 - transparent dressings
1 - sharps container