Nicotine Replacement Therapy Inpatient Order Sheet Date/Time:______________________ / _____________________ Patient smokes _____ cigarettes per day Patient smokes the first cigarette _____ minutes after awakening NICOTINE REPLACEMENT THERAPY ORDERS Remove all nicotine products in the patient’s room and send home with family prior to beginning nicotine replacement therapy Select ONE replacement therapy: Nicotine Transdermal Patch ____Apply 14 mg patch topically every 24 hours rotating sites for patient using 10 or less cigarettes /day ____Apply 21 mg patch topically every 24 hours rotating sites for patient using 10 or more cigarettes /day OR Nicotine Polacriex Gum ____Chew 2 mg gum by mouth every 1 hour as needed for patient using less than 25 cigarettes / day ____Chew 4 mg gum by mouth every 1 hour as needed for patient using 25 or more cigarettes / day Instruct patient: Chew the gum slowly until it tingles. Then park it between the cheek and gum. When the tingle is gone, begin chewing again until the tingle returns. Repeat this process until most of the tingle is gone (usually about 30 minutes). Do not eat or drink for 15 minutes before using gum or while chewing a piece. OR Nicotine Polacrilex Lozenges ____Allow 2 mg lozenge to dissolve in mouth every 1 hour as needed for patient smoking first cigarette more than 30 minutes after first awakening ____Allow 4 mg lozenge to dissolve in mouth every 1 hour as needed for patient smoking first cigarette 30 minutes or less after first awakening Instruct patient: Do not eat or drink for 15 minutes prior to or during the use of a lozenge. The lozenge should be sucked on until it dissolves. Do not bite, chew or swallow the lozenge. Physician signature: ______________________________________________
Nicotine Replacement Therapy Inpatient Order Sheet Date/Time:______________________ / _____________________ Patient smokes _____ cigarettes per day Patient smokes the first cigarette _____ minutes after awakening NICOTINE REPLACEMENT THERAPY ORDERS Remove all nicotine products in the patient’s room and send home with family prior to beginning nicotine replacement therapy Select ONE replacement therapy: Nicotine Transdermal Patch ____Apply 14 mg patch topically every 24 hours rotating sites for patient using 10 or less cigarettes /day ____Apply 21 mg patch topically every 24 hours rotating sites for patient using 10 or more cigarettes /day OR Nicotine Polacriex Gum ____Chew 2 mg gum by mouth every 1 hour as needed for patient using less than 25 cigarettes / day ____Chew 4 mg gum by mouth every 1 hour as needed for patient using 25 or more cigarettes / day Instruct patient: Chew the gum slowly until it tingles. Then park it between the cheek and gum. When the tingle is gone, begin chewing again until the tingle returns. Repeat this process until most of the tingle is gone (usually about 30 minutes). Do not eat or drink for 15 minutes before using gum or while chewing a piece. OR Nicotine Polacrilex Lozenges ____Allow 2 mg lozenge to dissolve in mouth every 1 hour as needed for patient smoking first cigarette more than 30 minutes after first awakening ____Allow 4 mg lozenge to dissolve in mouth every 1 hour as needed for patient smoking first cigarette 30 minutes or less after first awakening Instruct patient: Do not eat or drink for 15 minutes prior to or during the use of a lozenge. The lozenge should be sucked on until it dissolves. Do not bite, chew or swallow the lozenge. Physician signature: ______________________________________________