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Summer 2000

Camper name: ______________________________________________ ______________________________________________
Introduction:
The standing orders or nurse-initiated orders are medications and/or activities approved by a
camp-consulting physician. Medications listed are PRN (as needed) and exemptions to the
medication administration of the said drug(s) include the following:
1) Those with allergies, sensitivities or questionable reactions
2) Is currently taking a medication that is contraindicated with the said drug
3) Has been prescribed a medication by a physician for the symptom being treated
4) Causes extreme drowsiness or any other side effect that is less desirable then the reason for
taking the drug
5) Parents, guardians, family physician may reject the standing orders for any reason or cause.
A "12 hour period" refers to continuous administration during a 12-hour period ex. q 4-6 h. med
given every 4 or 6 h. in 12 hours.
"Guardians" refers to traditional definition and may include any institutional or Adult Residential
Centre facility etc. where the camper may reside. We only require the signature from
either the camper's Physician or from the camper's guardian.


Consent


I have read and authorize the attached:

Camp Physician's Signature:________________________________
Camper Physician's Signature:______________________________
OR
Guardian Signature:______________________________________ Date:____________
Camp Nurse: __________________________________
Camper name: ______________________________________________ ______________________________________________ Adult Camper

Activity as tolerated
Diet as tolerated
Acetaminophen 325-650mg po/pr q4-6hr for pyrexia (fever) x2
Acetaminophen 325-650mg po/pr for minor aches and pains, menstrual cramps, headache
ASA 325-975mg po/pr for pyrexia if unable to take acetaminophen
Solarcaine cream/spray or equivalent for sunburn
Calamine/Caladryl for itchiness due to insect bites
Benadryl 25mg po for symptoms of hay fever
Gravol 50-100mg po/pr for nausea/vomiting q6hr x 12hr
Over the counter antibiotic preparations for infected wounds with no previous treatment plan
Maalox 15-30 cc po for indigestion
Kaopectate 1200mg for diarrhea or loose, malodorous bowel movement
Stock cough syrup at recommended dosage
Consent


I have read the attached and authorize Schedule B

Camp Physician's Signature: _____________________________________
Camper's Physician's Signature: ___________________________________
Guardian Signature ____________________________________________ Date: ____________
Camp Nurse: ________________________________________

Please read and sign as applicable to the specific camper. If not applicable for camper, put
a diagonal line through the order and sign the page.

Camper name: ______________________________________________ Consistency with plans at home/facility or requested by family physician. If no plan is given, the following will be followed and adjusted to individual needs. If no bowel movement x 2 days, and is abnormal per usual pattern, then: push fluids, encourage activity, dried or fresh fruit. If no bowel movement x 3 days, previously prescribed oral laxative; if no prescription then continue with fluid push, Magnolax 7.5-15 ml (adults), Magnolax 1-10 ml (children) po, followed by or mixed with 240 cc water or milk at bedtime and rectal check. If no bowel movement x 4 days, then rectal check, glycerine or Dulcolax suppository, repeat laxative. If no bowel movement x 5 days, rectal check, abdominal assessment, disimpaction or fleet enema (action depends on camper, assess and rectal touch). How often does client have a normal bowel movement on average? ___________________ Are aggressive measures e.g. suppositories, laxatives, enemas etc necessary to achieve this? Yes
Consent

I have read the attached and authorize Schedule C

Camp Physician's Signature: _____________________________________
Camper's Physician's Signature: ___________________________________
Guardian Signature ____________________________________________ Date: ____________
Camp Nurse: ________________________________________
* Please read and sign as applicable to the specific camper. If not applicable for camper,
put a diagonal line through the order and sign the page.

Source: http://www.easterseals.ns.ca/documents/Camp_Tidnish/NIO%20Adult.pdf

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