Use of this site and material contained on its pages is for EDUCATIONAL USE ONLY.
 
Pharmskills Online - Test & Treat Services


 

 
Note: this is patient variation #2.
73
  bpm
Heart Rate
102/68
  mmHg
Blood Pressure
95
  %
O2 Saturation
16
  bpm
Respiration
99.3
  °F
Temperature (oral)

 
First Name:    Last Name:   
Date of Birth (MM/DD/YYYY):    Age:   
Telephone:    Email:   
Address:    City:   
State:    Zip Code:   
Primary Healthcare Provider:   
Medication Allergies:   
Current Medications:   
Treatments tried for current condition:   


Are you 18 years of age or older?


Are you pregnant or breastfeeding?


Have you ever been diagnosed with a weakened immune system (e.g., cancer, HIV/AIDS, transplant, long-term steroids, etc.)?


Do you require supplemental oxygen therapy?


Are you a resident of a nursing home or long-term care facility, in hospice, or receiving home health services?


Do you have a pending test for your flu-like symptoms (COVID, strep, flu)?


Have you tested positive for influenza in the previous four weeks?


When did your flu-like symptoms start?


Do you have any of the following symptoms
(indicate all that apply)?




  Do you have any of the following?
Physical Assessment
(please record values)		 Refer to PCP
if determined clinically unstable in pharmacist professional judgment or any of the following criteria
Blood Pressure
 
Systolic: mmHg
 
Diastolic: mmHg		 Systolic blood pressure < 90 mmHg or
Diastolic blood pressure < 60 mmHg
Respiratory Rate: bpm Respiratory rate > 30 breaths/min (single criteria);
Respiratory rate > 20 breaths/min (dual criteria)
Oxygen Saturation: % Oxygen saturation (SpO2) < 90% via pulse oximetry
Pulse: bpm Pulse > 125 beats/min (single criteria);
Pulse > 90 beats/min (dual criteria)
Temperature: °F > 103 °F (oral), or
> 102 °F (temporal), or
> 104 °F (tympanic) (single criteria);
< 96.8 °F (single criteria);
> 100.4 °F (dual criteria)
Acute altered mental status
 
          		 Yes
BCA
QuickVue® Influenza A+B Test  (Quidel, Lot# 292954, Exp Date: 2/27/2029)
POC Test Manufacturer:
 POC Test Lot#:
 POC Test Exp Date:
Influenza Diagnosed:               
Antiviral Treatment Prescribed:               
Refer to PCP:               

 
Influenza Adult Treatment
Instructions: the pharmacist is authorized to order and dispense the following antiviral agents to a patient that meets the evaluation inclusion criteria unless an identified contraindication applies for the patient.
 
  1. Oral Oseltamivir (Tamiflu)
    1. Contraindications
      1. Known hypersensitivity to oseltamivir or any component
      2. Patients 18 years and older with CrCl < 10 mL/min.
        1. If the pharmacist is unable to obtain a current CrCl for a patient with a history of chronic kidney disease (i.e., creatinine clearance (CrCl) < 60 mL/min, reduced kidney function, etc.), then the patient should be excluded from receiving Tamiflu.
        2. For purposes of this Protocol, current CrCl means a lab value obtained within the past six months and documented by a physician’s office, laboratory, or patient electronic health record, or reported by the patient and the pharmacist determines in their clinical judgment the patient report is accurate. The pharmacist shall document this information in the patient record.
    2. Dosing – all doses to be administered x 5 days
      1. Patients 18 years and older: 75 mg twice daily
      2. Patients 18 years and older with renal impairment
        1. CrCl > 60 mL/min: no dosage adjustment necessary
        2. CrCl 30 to 60 mL/min: 30 mg twice daily
        3. CrCl 10 to 30 mL/min: 30 mg once daily
  2. Oral Baloxavir Marboxil (Xofluza)
    1. Contraindications
      1. Known hypersensitivity to baloxavir or any component
      2. Weight < 40 kg
    2. Dosing – all doses to be administered as a single dose
      1. Weight-based
        1. 40 kg to < 80 kg: 40 mg
        2. 80 kg and above: 80 mg
  3. Inhaled Zanamivir (Relenza Diskhaler)
    1. Contraindications
      1. Known hypersensitivity to zanamivir or any component (contains milk proteins)
      2. Underlying respiratory disease or asthma
    2. Dosing – all doses to be administered twice daily x 5 days
      1. 10 mg (two 5 mg inhalations)
Documentation of rationale for treatment selection:
Dispense: 75 mg #10, no refills Sig: i po BID x5 days

     (CrCl: 30-60 mL/min)		 Dispense: 30 mg #10, no refills Sig: i po BID x5 days

     (CrCl: 10-30 mL/min)		 Dispense: 30 mg #5, no refills Sig: i po QD x5 days
Dispense: 1 inhaler, no refills Sig: 2 inhalations po BID x5 days

     (≥ 80 kg)		 80 mg x 1, no refills Sig: i po now

     (40 to <80 kg)		 40 mg x 1, no refills Sig: i po now