Exclusions

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What type of Head ache?
Exclusions Severe head pain REFER Lasts for 10
days lt 7 YO Signs of infection/high fever History
of liver disease Symptom consistent with migraine
without forma diagnosis
Headache
Precautions for Analgesics Do not use longer
than 10 days Use if you consume gt3 a
drinks Exceed recommended dosages NSAIDS/Salicilat
es Do not Take last trimester Take sal if under
15 YO Take if you have stomach problems Take
aspirin if you are taking anticoagulants,
diabetes meds, gout or arthritis unless
supervised Take ketoprofen if lt 16 YO Take
naproxen if lt 12 YO Ringing in the ears can be a
sign of toxicity Acetaminophen Do not drink Take
if you have liver problems
NonPharmalogical Migraine
Avoid Diet (caffeine, alcohol, meds) Missing
meals Stress Can use ice pack with applied
pressure to temples Tension Practice methods of
coping with stress Massages Avoid caffeine
because of rebound headaches
Patient Education Only take pain reliever up to 3
days per week Pain relief should begin in 15-60
minutes If BP problems ONLY APAP Take no more
than 1000mg in single dose Using HA meds more
than 3 days a week can cause rebound
headaches Decongestant can be use with analgesic
for sinus headache
Doses for NSAIDS, Aspirin, and Tylenol
Special Questions Does your face hurt when you
bend over? Do you use a computer a lot? Are you
under a lot of stress? Do you go a long time
between meals?
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Oral Pain and Discomfort
Exclusions REFER Cavity Loose fitting
dentures Loose/broken teeth Severe pain with
hot/cold or chewing RAS/HSV Lesions gt14
days Fequently occuring lesions Systemic
illness Compromised immunity Xerostomia Decrease
denture wearing time
Aphthous Stomatitis Canker sore Benzocaine or
other topical anal. Clean with hydrogen
peroxide Use protectants (Orabase Plain) or
denture adhesive to coat NonPharmalogical Get
more B12 or folate in diet Avoid spicy food Avoid
sharp foods Apply ice in 10 min increments Apply
baking soda paste Rinse with salt water or
Listerine Follow up Call if lesions dont start
clear within 7d Dont clear within 14d Symptoms
worsen Fever,rash or swelling develop Do not use
aspirin in the mouth and hold it on lesion
Teething Benzocaine 7.5 NTE QID Ex Orajel or
Anbesol Benzocaine 10 only _at_ night Tylenol
15mg/kg or Ibprofen 7.5 NonPharmalogical Massage
gums Frozen pacifier Cold, wet wash cloth Call
if Child vomits or diarrhea Symptoms not typical
of teething
Dry mouth Use artificial salivia products Ex
hydroxyethylcellulose, sodiumcarboxymethylcellulos
e Use topical floride NonPharmalogical Avoid
tobacco products Alcohol Antihistamines Caffiene S
ugar and acidic foods Do Chew gum with
xylitol Use soft toothbrush
Herpes Simplex Cold sore Benzocaine or other
topical anal. Camphor NTE 3 Menthol NTE 1 Do
not apply hydrocortisone May use triple
antibiotic 3-4xd If desired oral analgesic
ok Apply Docosanol 10 when symptoms present to
shorten duration of lesion NonPharmalogical Wash
lesions with soap Wash hands frequently Avoid
stress, wind, excess sun, fatigue Use lip and
face sunscreen Follow up Same as canker sores
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Questons to Ask
Are you taking any medications (including OC, OTC
and herbal supplements)? Are there any medical
conditions I should know about? Are you allergic
to anything? Do you have any allergies? Are you
pregnant or considering becoming pregnant? How
old are you? What is your approximate weight?
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Questions to Ask

• Where are your symptoms?
• On a scale of 1-10 how severe are your symptoms,
  10 being the worst?
• Are you having any other symptoms?
• Have you tried anything to alleviate these
  symptoms?
• Have you had these symptoms before?
• How long have you had these symptoms?
• Where were/are you when these symptoms occur?
• How is this ailment affecting you?

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Heart Burn or Dyspepsia
Exclusions Frequent gt 2 x a week REFER Frequent
gt 3 m HB while taking HB meds (PPI, H2RA,) HB
that continues after 2 w of treating Severe
HB Nocturnal HB Difficulty swallowing Vomiting
blood or black tarry stool Unexplained weight
loss Chronic hoarsness, wheezing or
cough Continuous N/V/D Pregnant or Nursing
mothers Children lt12 lt 18 for omeprezol

Non-Pharmalogical Avoid Foods that cause
symptoms Ex fatty, caffeinated, carbinated,
acidic Can keep food journal Large meals Tight
clothes Smoking Eating right before bed
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Minor foot disorders
Exclusions Diabetes Asthma Causative factor
unclear Unsuccessful initial treatment Worsening
of condition Signs of secoundary infection
(oozing, bad odor) Fever, Malaise Peripheral
circulatory disease Rheumatoid arthritis Toenail
infection Warts Painful plantar warts On face,
toenails or genetalia Fungus Nails or scalp
involved Face mucus membrane or genetalia
involved

Creams and Lotions most effective dosage
form Use sprays and powders for
prevention Apply keratolytic agent (whitefields
ointment) to horny layer first SE skin
irritations, burning, stinging
Non-Pharmalogical Fungus Wear sandal Shower
shoes Cleans skin daily Allow shoes to dry Use
odor controlling insoles Put socks on first Use
separate towel for that area Warts It is a
virus, keep good hygiene Do not probe, poke or
cut
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Preventing pregnancy
EC How it works Suppression of
ovulation Interferes with fertilization,
transport of the fertilized egg to uterous, and
inhibits implantation Things to know Must be 18
YO Must show ID 89 effective NOT 100 TAKE
within 3 days of unprotected sex (Sooner the
better) 1st pill stat then next 12 h later Or
both at once The split helps with nausea Side
effects Nausea Breast tenderness Early or late
onset of prego Heavier or lighter menses Call PCP
if menses do not return w/I 3 weeks
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Vagina disorders
Exclusions REFER Pregnacy lt12YO Concurrent
symptoms fever, pain in lower abs, back and
shoulders Meds that perdispose to VVC
corticosteriods, antineoplastics,
antibiotics Recurrent VVC (4 w/I 12m)
Non-Pharmalogical Decrease sucrose intake and
refine carbs Consume live yogurt
cultures Discontinue drug causing it
Single dose and 7 day treatments have been
compared resulting in similar cure
rates Monistat1 can be administer during the
day SE burning, itching irritation
Applying vaginal anti-fungals Usually start
before going to bed Wash and dry entire vaginal
area Place cream/suppository as far back in
vagina as possible If desired, wear sanitary pad
to absorb leakage Use for the length of time
indicated even if menstrual flow
SEE PCP Symptoms return with in 2m Vaginal
symptoms occur gt 3 X in 12m Symptoms do not
improve within 3 days Bad smelling, frothy or
discolored discharge
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Menstrual disorders
Primary Dysmenorrhea Difficult or painful
menstration Cramplike abdominal pain at the time
of menstration In the absense of Pelvic
Disease Secondary Dysmenorrhea Onset after
25 Pain at other times other than onset of menses
Exclusions REFER Severe dysmenorrhea Sympoms.
Inconsistent with primary dismenorrhea History of
PID, infertility, irregular menses,
endometriosis, ovarian cysts Use of IUD Allergies
to NSAIDS Use of warfarin, heparin or
lithium Active GI disease PMS Uncertain pattern
of symptoms Severe PMS Onset coincides with OC or
HRT
Primary treatment for dysmenorrhea Theses
agents inhibit the production of prostaglandins,
which stop strong contractions (cramping) of the
uterus Optimal pain relief is achieved when
these agents are taken on a schedule rather than
an as needed Therapeutic effect 30-60 min SE
GI symptoms (v/d, HB, ab pain, constipation,
anorexia) HA and dizziness Take with food to
limit these SE
Non-Pharmalogical Rest Heat Loose
clothing Exercise Massaging where it
hurts Smoking and second hand smoke associated
with more severe symptoms PMS Aerobic
exercise Dietary modifications Congnitive
behavioral therapy Stress management
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Minor Wounds and Burns
Exclusions REFER wounds Contains foreign
matter Chronic wound Bite from animal or
human Signs of infection Involvement of face,
mucous membrane or genitalia Deep acute
wound Burns BSA of 2 or more On eyes, ears, face
hands feet perineum Chemical or Electrical Person
of advanced age Person with multiple medical
disorders immunocompromised
Exclusions
Burn Treatment Immerse the affected area in cool
tap water for 10 30 min Cleanse with water and
mild soap Apply nonadherent dressing or skin
protectant For blistering use hydrocolloid
dressing Do not rupture blister Burns (unbroken
skin) treat infected area with skin protectant or
topical anesthetic with tissue If skin is broken
use topical antibiotic NSAIDS can be used for
pain For a burn see PCP if signs of healing do
not occur with in it is 7 days

• Stages of wound healing
• Inflammatory phase
• lasts 3-4 days
• prepares the wound for repairs
• Proliferative phase
• New connective tissue is formed in the wound
• Starts day 3 and lasts for 3 weeks
• Maturation phase
• Starts week 3 and lasts for 2 years
• New collagen replaces week collagen
• Results in scar that is 70-80 as strong as
  original skin

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ACNE
Exclusions REFER Grades II-IV Taking
a comedogenic drug Possible roscea onset
20-60YO, Location more on central part of face
CAUSES Excessive scrubbing Medication Use
(PIMPLES) Stress Hormones Oil based
cosmetics Genetics Humid environments Touching
the face Prolonged sweating Oily products used in
hair
Non Drug non prescription Treatment Wash face
with mild soap two times a day Avoid things that
cause acne Dont use abrasive cleaners Acne
lesions should not be picked or squeezed Benzoyl
peroxide Salicylic acid Sulfur
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Sun Burns
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Skin problemsDry skin/Atopic dermatitis
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Dandruff, Seborric dermatitis, Psoriasis
Dandruff, seborrhea, Psoriasis no improvement
after 1-2 week see PCPExema noticable
impovement should be seen in 24-48 hoursDry
skin improvements should be seen with in 24
hoursContact dermatitis should subside in 14-21
days, if symptoms become worse or rash spreads
call PCP
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Insect bites and pediculosis
Pediculosis (lice) Non drug Careful visual
inspection Combing with nit comb Combs, brushes,
towels, caps, ect not to be shared Clothing and
bedding and car seats should be washed in hot
water and machine dried Or put in plastic bags
and sealed for 2 weeks Vacuum regularly Possibly
head shave Drugs Synergized pyrethrins Block
nerve impulse transmission causing insect
paralysis and death Indication head and pubic
lice crabs Permethrin Disrupts Na channels
delaying repolarization causing paralysis Only
for head lice DO NOT HAVE TO REPEAT Good
hygeine Kills body lice cooties Occlude with
petroleum Eye lashes, facial hair
Insect stings Non drug Remove stinger quickly Ice
in 10 min intervals Avoid perfume Bright
colors Wear shoes Use DEET or Picaridin Drugs Loca
l anesthetics (benzocaine) Topical antihistamines
(diphenylamine) Counterirritants
(menthol) Hydrocortisone Skin protectants
(calamine) 3-4 times a day for 7 days

• Refer
• Hives
• Excessive swelling
• Dizziness
• Nausea
• Weakness
• Response away from bite
• Previous sting
• Previous severe reaction
• Personal or family history of allergic reaction
• lt 2 YO

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Epi Pen

• Directions for use
• 1. Remove cap (yellow or green)
• 2. Grasp in fist with black tip pointing
  downward
• 3. Pull off grey safety release
• 4. Hold black tip near thigh
• 5. Swing and jab firmly into outer thigh
• 6. Hold firmly against the thigh for 10 seconds
  
• The window will be red when injection is complete
  
• 7. Remove from thigh and massage area of
  injection for 10 seconds
• 8. Note time of injection
• 9. Call 911 or go to Emergency Department
• 10. Put used EpiPen back into storage holder and
  take with patient to ED
• 11. Give used EpiPen to attending physician for
  examination and tell them when injection was
  given

• Symptoms of Anaphylaxis
• May occur within seconds to more than an hour
• Flushing, itching, hives
• Rapid, irregular pulse
• Feelings of anxiety
• Swelling of the throat and tongue with breathing
  difficulty
• Symptoms of rhinitis or asthma
• Runny nose, sneezing, wheezing
• Vomiting, diarrhea, stomach cramps
• Low blood pressure, light-headedness, loss of
  consciousness

• Important notes
• Protect from extreme heat or cold
• Be aware of the expiration date
• Examine contents of the auto-injector
  periodically to make sure that solution is clear
  and does not contain any particulates
• Make sure that family and friends of patient are
  instructed on use
• Consider requesting multiple pens, for home,
  school, work etc.

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Ano-rectal disorders

• Exclusions
• Anorectal disorder in patients lt 12 YO
• Diagnosed GI disease associated with colorectal
  bleeding
• Family history of colon cancer
• Abcess, fistula, fissure, neoplasm, malignancy,
  polyps
• Sever pain, bleeding, seepage, prolapse,
  thrombosis, black tarry stools
• Severe itching, burning, inflammation, swelling
  and discomfort
• Symptoms that do not respond in 7 days of
  treatment

Treatment Non pharmalogical Maintain hydration
and healthy diet Increase amount of water and
fiber Clean anorectal area with wipe after each
BM Sitz bath for 5 min 2-3 times a day Non
prescription Local anesthetics Vasoconstrictors
(only ephedrin and phenylephedrine
inside) Protectants (not glycerine
inside) Analgesic/anesthetics/antipruritics kerato
lytics
What are hemorrhoids? Abnormally large, buldging,
symptomatic clusters of hemorhoidal vessels,
supportive tissues, and overlying mucous membrane
in the anorectal region Hemorrhoid may originate
either from superior hemorrhoidal vein, producing
internal hemorrhoids or form the inferior
hemorrhoidal vein forming external
hemorrhoids Causes Hemorrhoid develop with
increasing age when muscle fibers become
weakened Diet, of meals per day and lifestyle
may be linked to hemorrhoidal formation Hormonal
changes and the size of the uterus lead to
formation of hemorrhoids' during pregnancy
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Constipation
Drugs causing Analgesics Anticholinergics Cation
containing agens iron supplements,
aluminum Neutrally active ingredients opioids,
antihypertensives,

• Exclusions
• Marked ab pain distention/cramping
• Unexplained flatulence
• Fever
• n/V
• Paraplegia/quad
• Daily laxative use except natural things
• Unexplained bowl habits
• esp. accompanied by weight loss
• Change in caliber of stool (pencil thin)
• Bowl symptoms that persist for 2 weeks
• or recur over 3 months
• Bowl symptoms that recur after treatment
• History of IBD
• Non Pharmalogical
• Eat more fiber 20-35g/day, drink water, exercise

Chronic constipation must contain 2 of
the following Straining during 25 or more of
defications Lumpy or hard stool in 25 or more of
defications Sensation of incomplete evacuation
25 or more of defications Sensation of anorectal
blockage in 25 or more of defications Manual
maneuvers to facilitate in 25 or more of
defications lt3 defications per week
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Adult Urinary Incontinence Consult PCP
Prevalance 50 for people in nursing homes and
2-55 for adults living in the community
General patient information Guards and shields
60-360mL light to heavy capacity Undergarmentsn36
0-540mL moderate to heavy Briefs 840-1000mL
moderate to heavy Roll on bed application and
adhesive closures best for patients unable to
change themselves Absorbant bed and chair pads
can be used additionally Check skin for
irritation and maceration every 2 hours If urine
loss continual change q 2-4h Use protectants
labeled for diaper rash if needed Chorophyll
containing products can be used to decrease
odor If pressure ulcers occur see PCP Identify
and eliminate foods, liquids, or other substances
that can irritate the bladder (e.g. coffee, tea,
soda, alcohol, chocolated, acidic juices, tomato
based sauces, spicy foods, artificial sweeteners,
and nicotine.) Avoid scented powders and bath
products. Use white toilet paper.
Risk Factors Immobility/chronic disease
state Impaired cognition Medications Hyperglycemia
Hypercalcemia Obesity Pregnancy Smoking Delirium
Low fluid intake Environmental barriers High
impact physical activities Diabetes Stroke Neurolo
gical disorders Estrogen depletion Pelvic floor
muscle weakness BPH/TURP/prostatectomy
Common complications Social isolation leads to
depression Restricting fluid intake can cause
dehydration Leads to drastic reduction of quality
of life, nursing home Falls and fractures
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Pyrantel pamoate 11mg/kg orally NTE 1gmShake
liquid formulation wellMay be taken with food,
milk, juices or on an empty stomach any time of
day. The fluid form may be mixed with milk or
fruit juice.SE Ab cramps, N/V/D, rash, HA,
drowsiness or dizziness occurs but if persists
after taking medicine call PCPIf symptoms of
pinworm persist beyond 2 weeks, contact PCP
Refer Liver disease Anemia Pregnancy Breast
feeding lt2 YO lt 25 lbs Vague symptoms and
negative visual inspection Need for repeated
dosages
Pinworm
How do I get pinworm? Pets cannot give children
pinworm Effects all socioeconomic groups, is not
a dirt problem Spread person to person via anus
to mouth Child scratches their bottom then
touches something Eggs can remain infective for
several days on bedding dust and air Sexual
transmission may occur through oral anal sex
Non-pharmalogical Wash bed linens towels and
clothes of family in hot water during the
treatment period. (Do not shake) Eggs are
destroyed by sunlight open blinds and
curtains Have family members take a daily morning
shower to wash perianal area (avoid baths) Use
disinfectants on toilet seats Vacuum (do not
sweep) wet mopping also limits spreading
pinworm eggs in the air Wear closefitting shorts
under one piece pjs to stop the spread of
pinworms from perianal region to the perineal
region After BM use soap and toothbrush to clean
under fingernails. Trim nails and wash hands
frequently
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Diarrhea and intestinal gas
Refer lt 6 months old Severe dehydration --children
showing behavioral changes --children who have
not urinated in 8 hours --children who have no
tears Children with persistant high fever Blood
or mucus in stools Severe ab pain Pregnacy Chronic
diarrhea Immunosuppression Lasts over 48 hours
Treatable Food allergies Lactose intolerant Acute
diarrhea
NON DRUG THERAPY Diarrhea Avoid fatty foods,
simple sugars, spicy foods Avoid caffiene Oral
re-hydration therapy Gas Relax before
eating Dont rush through meals Chew food
thoroughly Avoid washing foods down with
beverage Avoid staw and gulping Keep journal and
record what makes you gassy Avoid whipped or
carbonated foods
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Nausea and vomiting
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Insomnia