Medication Table

Include ALL SCHEDULED MEDICATIONS; Include ONLY PRN MEDICATIONS given for pain, nausea, and any PRN
medication given in the last 24 hours. Table must be typed, neat, and easy to read.
DRUG
(3 points)

DOSE/ROUTE
(3 points)

CLASSIFICATION
(3 points

WHY IS PATIENT
TAKING MED?
(disease/diagnosis)
(3 points)

DATA NEEDED
BEFORE/AFT
ER
ADMINISTERI
NG MED- I.E.:
B/P, P, RESP,
LABS, ETC.
(3 points)

PERTINENT SIDE EFFECTS

(3 points)

Lactulose

20G/30ml PO 3x
Daily

Constipation

N/A

Simvastatin

10mg PO @
Bedtime

Laxative; Ammonia
detoxicant
Lactose synthetic
derivative
Antilipemic; HMGCoA reductase
inhibitor
Laxative, emollient;
stool softener;
Anionic surfactant

Hypercholestoremia

N/A

Constipation

N/A

Prevention of DVT
post R Hip Surgery

Check
Antifactor
Xa 4 hours
after
injection

Nausea, Vomiting,
abdominal cramps,
flatulence, distention,
hypernatremia
Liver Disfunction,
pancreatitis, myositis,
rhabdomyolosis
Bitter taste, throat
irritation, nausea,
anorexia, diarrhea,
cramps, rash
Hemorrhage from any
site, hypochromic
anemia, bleeding, edema,
thrombocytopenia

100 mg PO BID
Docusate Sodium

Enoxaparin

30 mg/0.3 ml
SubQ BID
0600 & 1800

Anticoagulant, antithrombotic,
Low-molecular
weight heparin

Acetaminophen

650 mg Q4H PO
PRN

Noopiod analgesic,
antipyretic

Mild to moderate
pain or
development of
fever

Pain rating

Opiate analgesic;
Semisynthetic
phenanthrene

Moderate to Severe
Pain

Pain rating

Hydromorphone

0.4 mg Q4H SubQ

PRN

Antiemetic

Prevents nausea

N/A

Ondansetron

4 mg Q6H SubQ
SubQ PRN

2 points for correct spelling and neatness. Total points possible: 20

Total points earned: _____

Hepatotoxicity. Hepatic
seizure, GI bleeding,
leukopenia, neutropenia,
hemolytic anemia,
thrombocytopenia,
jaundace, CNS
Stimulation, delerium
Seizures, sedatio,
euphoria, paliptations,
bradycardia or
tachycardia, changes in
BP, Tinnitus, blurred
vision, miosis,
respiratory depression,
nausea
Bronchospasm, muscle
pain, headache, dizziness,
fatigue, dry mouth,
hypoxia, wound
problems