Symptomatic relief formulary (Formularies)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • All NHS Highland
  • Secondary Care only
  • Adults only

Symptomatic relief is:

The safe administration of a range of medications to inpatients, given by a registered nurse from an agreed formulary to relieve specified symptoms without the need of assessment by a qualified prescriber. 

Symptomatic relief can only be administered by registered nurses if 'prescribed' on Kardex / HEPMA

Symptomatic relief allows treatment for the following symptoms:

  • Mild pain
  • Constipation
  • Diarrhoea
  • Dry skin
  • Indigestion.

All medicines are recognised 'over the counter' (OTC) medicines, either Pharmacy (P) or General Sales List (GSL) medicines. They should only be used for the indications listed, at the doses indicated and by the routes described. 

The decision to administer Symptomatic Relief, in the interests of patient comfort, is a matter of professional and clinical judgement. 

See Symptomatic Relief Flowchart to aid decision making.

Escalation

In most cases, symptoms detailed within symptomatic relief formulary will be as the result of minor illness or symptoms only.

However an urgent referral to an appropriate medical / nurse practitioner must be made if:

  • In doubt or symptoms worsen.
  • Patient has been administered one enema in a 24-hour period with no relief of symptoms.
  • Patient has been administered two doses of other medicines in a 24-hour period with no relief of symptoms.
  • If a medication is required for two consecutive days.

MEDICINE MAIN INDICATION CODE LETTER
Paracetamol Mild to moderate pain only A
Senna / sennosides Constipation B
Glycerol suppositories Constipation C
Sodium citrate enemas Constipation D
Oral rehydration salts, eg Dioralyte® Diarrhoea E
Emollient ointment, eg Zerobase® ointment Dry skin emollient F
Emollient cream, eg Zerobase® cream Dry skin emollient G
Compound alginate: Peptac® Indigestion H

All patients meeting any of the following criteria must have extra consideration to any pre-existing contraindications and unknown or uncertain medication history.

Inclusion criteria: 

In order to be treated using symptomatic relief, patients must be:

  • Inpatient in a NHS Highland service.
  • Aged 16 years or older.
  • Under the care of a medical practitioner.
  • Prescribed ‘Symptomatic Relief’ by a prescriber.
  • Senior Charge Nurse for the inpatient area is in agreement that the Symptomatic Relief Formulary may be used.

Exclusion criteria: 

Patients meeting any of the following criteria must NOT be treated under symptomatic relief:

  • Documented allergy to the medicine listed.
  • Contraindication to the use of the medicine listed.
  • Patient with pyrexia. NB paracetamol should NOT be used for anti-pyretic properties using symptomatic relief.

Paracetamol

 Code Letter: A

Indication
  • Mild to moderate pain

Products
  • Oral: 500mg tablets / caplets / soluble tablets
  • Oral: 250mg/5mL suspension
  • Rectal: 500mg suppositories

Dosage
  • Up to 1g may be given at any one time. Consider a dose reduction in patients with low body weight (less than 50kg) to 15mg/kg/dose or ONE tablet / ONE suppository. 
  • A minimum interval of 4 hours should be left between doses.
  • Use with caution in patients with liver or renal disease and patients with chronic malnourishment or chronic alcoholism, with dose reduction to 15mg/kg/dose.  

A maximum of TWO doses may be administered within 24 hours using this symptomatic relief policy. 

Cautions

NO MORE than 4 grams of paracetamol in TOTAL should be given in any 24 hours taking all routes and paracetamol-containing preparations into consideration. 

  • Before administration check the patient’s Kardex / HEPMA to ensure that the patient is not already taking paracetamol or another preparation containing paracetamol.
  • Common examples of paracetamol containing preparations are:
    • Co-codamol
    • Co-dydramol
    • Co-proxamol
    • Tramadol with paracetamol
    • Over-the-counter analgesics and cough/cold remedies.
  • The British National Formulary (BNF) contains a comprehensive list of paracetamol containing preparations.

If a paracetamol containing product has already been prescribed, a prescriber should be contacted for advice.

Legal status
  • P/GSL (but see paracetamol entry in BNF)

Properties
  • Paracetamol relieves pain and is effective in mild to moderate pain.
  • Paracetamol has anti-pyretic properties (ie reduces temperature) but SHOULD NOT be given to patients for this purpose using this symptomatic relief formulary. An appropriate practitioner must be contacted in this instance to assess patient.
  • Paracetamol causes little gastric irritation.
  • Paracetamol has NO anti-inflammatory activity.
  • Soluble tablets or suspension are less cost-effective and should ONLY be used when the patient has difficulty swallowing tablets. Also, the suspension can involve a large volume of liquid to make up the dose.

Overdosing with paracetamol is particularly dangerous as it may, if untreated, cause hepatic damage, sometimes not apparent for 4 to 6 days.

Senna / sennosides

 Code Letter: B

Indication
  • Constipation
  • General aim: a minimum of 3 bowel movements per week.

Products
  • Oral: 7.5mg tablets
  • Oral: 7.5mg/5mL syrup 

Dosage
  • Up to TWO tablets or 10mL (measured using oral syringe / medicines cup) of syrup may be given at any one time.
Cautions
  • Stimulant laxatives increase intestinal motility and often cause abdominal cramps. 
  • Senna should NOT be given to patients with:
    • Intestinal obstruction
    • Recent gastrointestinal surgery
    • Acute or chronic gastrointestinal conditions, such as inflammatory or ulcerative bowel conditions
    • Who have blood or mucus in stools.

Legal status
  • GSL

Properties
  • Senna is an effective stimulant laxative.
  • Onset of action is 8 to 12 hours. 
  • The tablets are more cost-effective than the syrup but some patients may find the syrup easier to swallow.

Glycerol suppositories

 Code Letter: C

Indication
  • Constipation

Products
  • Rectal: 4 gram suppositories 

Dosage
  • ONE suppository may be inserted into the rectum at any one time. 
  • Moisten each suppository in water before use.
Administration
  • Before administering: be sure that the constipation is not secondary to an underlying complaint.
  • Lubricate the blunt end of the suppository. Separate the patient's buttocks and gently insert the suppository, blunt end first, advancing for about 2 to 4cm. 
  • Repeat this procedure if additional suppositories are to be inserted. 
  • Ask the patient to retain the suppository for 20 minutes or until they are no longer able to do so.
Cautions
  • Glycerol suppositories should NOT be used:
    • In acute gastrointestinal conditions
    • Recent anal / rectal surgery.
    • In patients who have an anal fissure or haemorrhoids
    • In patients who have an inflammatory or ulcerative bowel condition
    • If there is blood or mucus in stools.

Legal status
  • GSL

Properties
  • Glycerol suppositories soften hard stools and cause mild irritation, which has a stimulant action.

Sodium citrate enemas

 Code Letter: D

Indication
  • Constipation

Dosage
  • Only one enema should be administered at any one time.
  • Only one enema may be administered in any 24 hour period.
  • If there is no effect within 48 hours of administration consult an appropriate practitioner.
Administration
  • Before administering: be sure that the constipation is not secondary to an underlying complaint.
  • Lubricate the nozzle with a drop of the contents. 
  • Expel excessive air from the enema and gently introduce the nozzle slowly into anal canal to a depth of 10 to 12.5cm while separating the buttocks. 
  • Squeeze the tube until the total contents have been administered. 
  • Slowly withdraw nozzle and ask the patient to retain enema for 10 to 15 minutes before evacuating bowel.
Cautions
  • Do NOT administer in:
    • Inflammatory or ulcerative bowel disease.
    • If the patient has had recent anorectal surgery.
    • To patients with known bowel obstruction.
  • Sodium citrate enemas may cause the following, if this has occurred in the past, DO NOT administer: 
    • Intolerable cramps
    • Anal canal irritation
    • Profuse diarrhoea and fluid loss rectally

Legal status
  • P

Properties
  • Constipation can be defined as the passage of hard stools, less frequently than the patient’s own normal pattern.
  • These enemas contain a mild osmotic and stimulant laxative.
  • They can be used for constipation in the rectum and sigmoid colon if senna, glycerin or bisacodyl suppositories are known to be ineffective.

Oral rehydration salts
Eg Dioralyte®

 Code Letter: E

Indication
  • Diarrhoea

Dosage
  • ONE sachet to be reconstituted EXACTLY in accordance with the manufacturers’ instructions included with each product and administered orally.
  • Solutions should be made up immediately before use.
Cautions
  • Oral rehydration salts should NOT be used:
    • For the self-treatment of chronic or persistent diarrhoea EXCEPT under medical supervision.
    • For self-treatment by patients with liver or kidney disease, patients on low potassium or sodium diets, or patients with diabetes. The use of oral rehydration salts in patients with these conditions, should be supervised by a medical practitioner.

Legal status
  • P/GSL

Properties

  • The combination of electrolytes and sugars stimulates water and electrolyte absorption from the gastrointestinal tract and therefore prevents or reverses dehydration in diarrhoea.

Emollient ointment
eg Zerobase® ointment

 Code Letter: F

Indication

Dry skin emollient or soap substitute

Products
  • Topical: eg Zeroderm® ointment (first line), Epaderm® ointment

Dosage
  • As an emollient: Apply liberally twice a day.
  • Ointment may NOT be applied more than twice daily when used as an emollient for symptomatic relief.
  • As a soap substitute: Use as often as required.
Cautions
  • For external use only.
  • Warning: Risk of severe and fatal combustible burns are extended to all (paraffin-based and paraffin-free) emollients. 
  • Advise patients: NOT to smoke or go near naked flames, and warn about the easy ignition of clothing, bedding, dressings, and other fabric that may have a build-up of emollient on them.
  • Care should be taken if emollient is used in the bath or shower, as the bath or shower surface is likely to become slippery.

Legal status
  • GSL

Properties
  • An emollient suitable for patients with dry skin. Can be used in all dry or scaling skin disorders to soothe, smooth and hydrate the skin. Can also be used as a soap substitute for hand washing or in the bath or shower.

Emollient cream
eg Zerobase® cream

 Code Letter: G

Indication
  • Dry skin emollient or soap substitute

Products
  • Topical: eg Zerobase® cream (first line), Diprobase® cream
  • NOT Aqueous cream as it commonly irritates

Dosage
  • As an emollient: Apply liberally twice a day. 
  • The effect of emollient cream is short-lived and so should be applied after improvement occurs.
  • Cream may NOT be applied more than twice daily if being used as an emollient for symptomatic relief.
  • As a soap substitute: Use as often as required.
Cautions
  • For external use only.
  • Warning: Risk of severe and fatal combustible burns are extended to all (paraffin-based and paraffin-free) emollients. 
  • Advise patients: NOT to smoke or go near naked flames, and warn about the easy ignition of clothing, bedding, dressings, and other fabric that may have a build-up of emollient on them.
  • Care should be taken if emollient is used in the bath or shower, as the bath or shower surface is likely to become slippery.

Legal status
  • GSL

Properties
  • An emollient, suitable for patients with dry skin. Can be used in all dry or scaling skin disorders to soothe, smooth and hydrate the skin.
  • Can also be used as a soap substitute for hand washing and in the bath.

Compound alginate: Peptac®

 Code Letter: H

Indication
  • Indigestion

Products
  • Peptac® liquid

Dosage
  • 10 to 20mL (measured using oral syringe/medicine cup) may be given at any one time for dyspepsia (indigestion) or reflux.
  • This should preferably be given 30 minutes after food and / or at bedtime.
  • DO NOT wash down with water as this will reduce the acid neutralising ability.
Cautions
  • Care should be exercised when a highly restricted salt diet is required, such as some renal and cardiovascular conditions.
  • Peptac is an antacid and can interact with other medication. An interval of 2 hours (before and after) should be given between the administration of antacids and other medication.

Legal status
  • P/GSL

Route of administration
  • Oral

Properties
  • Peptac® liquid has antacid and “rafting” properties. Peptac® reacts rapidly with acid in the stomach to form a raft that floats on the stomach contents to reduce gastro-oesophageal reflux. It also neutralises the acidity of the stomach contents.

The following record of administration must be documented:

Kardex

  1. Recording of date/time (in 24 hour format).
  2. The code/letter corresponding to the medication administered.
  3. The dose and route.
  4. Initial of administering registered nurse.

HEPMA

  1. Select 'Administration' tab then select 'PRN Medicines'.
  2. Select medication required to be administered.
  3. Confirm charted once administration has taken place.

The registered nurse administering from this formulary must be up to date with TURAS Medicines Management Module.

Also see Policy on the Administration of Medicines (intranet access required).

Editorial Information

Last reviewed: 27/02/2025

Next review date: 29/02/2028

Author(s): NMAHP Medicines Management Team.

Version: 1

Approved By: TAMSG of the ADTC

Reviewer name(s): E Gate, Medicines Management Development Nurse.

Document Id: AF013