Assessment Instructions And Cannulation Documentation Chart

Grading:

Each assessment task will be graded Satisfactory (S) or Not Satisfactory (NS).  A Satisfactory result in each assessment task must be attained to receive a competent outcome for the unit overall.

Re-assessment:

Should a result of Not Satisfactory (NS) be received any re-assessment is conducted as soon as practicable after you have been provided feedback on the areas that need to be readdressed.   You will be re-assessed only in the areas assessed as (NS). 

After re-assessment occurs should it still be evident an overall understanding of this unit has not been demonstrated a meeting with your Educator will take place to discuss options for further/varied forms of assessment or repeating of the unit of competency at a cost.

Should additional support be required it is your responsibility to request additional assistance or clarification as soon as possible after receiving initial feedback.

?

“I affirm that all work submitted within is my true and original work unless otherwise credited”

Student signature:

Date:

?

If completing and submitting this assessment electronically, please tick this box to acknowledge that by including your name in place of a signature above, it is deemed to be your signature for the purpose of this assessment.

Total =

Name of Educator marking:

Moderated by:

1.

2.

3.

4.

1.

2.

3.

CANNULATION DOCUMENTATION CHART

Affix patient sticky label

Visual Infusion Phlebitis Score

ACTION

I.V site appears healthy

  0

No sign of phlebitis

Continue to monitor and document once per shift  

? OBSERVE CANNULA      

One of the following is evident:

·    Slight pain near the I.V site or

·    Slight redness near the I.V site

  1

Possible first sign of phlebitis

Report to medical officer. Remove cannula and resite if required. Document in clinical record.

? OBSERVE CANNULA

Two of the following are evident:

  2

Early stage of phlebitis

Report to medical officer. Remove cannula and resite if required. Document in clinical record.

? RESITE CANNULA

·    Pale near I.V site

·   Erythema

·    Swelling

All of the following are evident

  3

Medium stage of phlebitis

Report to medical officer. Remove cannula and resite if required. Document in clinical record.

? RESITE CANNULA   ? CONSIDER TREATMENT

·    Pain along path of cannula

·    Erythema

·   Induration

All of the following are evident & extensive

  4

Advance stage of phlebitis or start of thrombophlebitis

Report to medical officer. Remove cannula and resite if required. Document in clinical record.

? RESITE CANNULA   ? CONSIDER TREATMENT

·    Pain along path of cannula

·  Induration

·    Erythema

·   Palpable venous cord

All of the following are evident and extensive

  5

Advanced stage of thrombophlebitis

Report to medical officer. Remove cannula and resite if required. Document in clinical record.

? INITIATE TREATMENT  ? RESITE CANNULA

·    Pain along path of cannula

·  Erythema

·    Palpable venous cord

·   Induration

·   Pyrexia

Check Site Once Per Shift

INSERTION

CHECKS

REMOVAL

Date

Time

Score

Initial

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: …………………………

Date……………………….

Time……………………….

Size………………………………………………………….

Time: …………………………

Site:

L

R (please circle)

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Inserted by…………………………………………………..

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: …………………..

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: ……………………………

Date……………………….

Size………………………………………………………….

Site:

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Time: …………………………..

Inserted by………………………………………………….

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………….

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: ……………………

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: ………………………………

Date……………………….

Size………………………………………………………….

Time: …………………………….

Site:

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Inserted by………………………………………………….

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: ………………………

Check Site Once Per Shift

INSERTION

CHECKS

REMOVAL

Date

Time

Score

Initial

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: …………………………

Date……………………….

Time……………………….

Size………………………………………………………….

Time: …………………………

Site:

L

R (please circle)

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Inserted by…………………………………………………..

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: …………………..

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: ……………………………

Date……………………….

Size………………………………………………………….

Site:

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Time: …………………………..

Inserted by………………………………………………….

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………….

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: ……………………

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: ………………………………

Date……………………….

Size………………………………………………………….

Time: …………………………….

Site:

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Inserted by………………………………………………….

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: ………………………

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: ………………………………

Date……………………….

Size………………………………………………………….

Time: …………………………….

Site:

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Inserted by………………………………………………….

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: ………………………

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: ………………………………

Date……………………….

Size………………………………………………………….

Site:

Time: …………………………….

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Signature: ……………………

Print name: ………………………

Inserted by………………………………………………….

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Maximum time for other devices

as per MO Orders

Routine Change Due

Attach ADR Sticker

AFFIX PATIENT IDENTIFICATION LABEL HERE

ALLERGIES & ADVERSE DRUG REACTIONS (ADR)

? Nil known ? Unknown (tick appropriate box or complete details below)

UR No. 521 344

Drug (or other)

Reaction/Type/Date

Initials

Family Name: SINCLAIR

Given Names: Joel

Date of birth: 8/11/2000

Sex ? M ? F

Sign CBennett

Print C. Bennett

Date 18/9/17

1^st prescriber to Print Patient Name and Check Label Correct:

……………………………………………..

Patient Weight (kg)………………

Height (cm)……………………

FACILITY / SERVICE: …………………………………

Medication Chart           of  

? IV Fluid

? BGL/ Insulin

? Acute Pain

? Other

Ward/Unit: …………………………

? Palliative Care

? Chemotherapy

? IV Heparin

ONCE ONLY, PRE-MEDICATION, TELEPHONE ORDERS & NURSE INITIATED MEDICINES

(Telephone orders MUST be signed within 24 hrs of order)

Date Prescribed

Medication

(Print Generic Name)

Route

Dose

Date/Time

Prescriber/Nurse Initiator (N)

Time Given

Pharmacy

18/9/17

Paracetamol

PR

Igm

0130

Medicines taken Prior to Presentation to Hospital (Prescribed, over the counter, complementary)

Own medications brought in? ? Y ? N

Administration aid? …………………. (Specify)

Medication

Dose & Frequency

Duration

Medication

Dose & Frequency

Duration

GP:

Community Pharmacy:

Documented by:                                           

(Sign)

(Date)

Medicines usually administered by:

AFFIX PATIENT IDENTIFICATION LABEL HERE

UR No:

Family Name:

Given Names:

Date of Birth:

Sex ? M ? F

1^st Prescriber to Print Patient Name and Check Label Correct: ………………….. Year 20 _______

Date

18/9/17

Medication (Print Generic Name)

Metoclopramide

Date

Prescriber’s Signature: ……………………… Print Name: ………………………….. Contact: ………………… Pharmacist: ………………….Date: …………….

Route

IV

Dose & Hourly Frequency

4/24

PRN

Max dose/24 hrs

6

Time

Indication

Nausea

Pharmacy

Dose

Route

Prescriber Signature

J.Johns

Print Name

J.Johns

Contact

22411

Sign

Date

Medication (Print Generic Name)

Date

Re-assessment:

Should a result of Not Satisfactory (NS) be received any re-assessment is conducted as soon as practicable after you have been provided feedback on the areas that need to be readdressed.   You will be re-assessed only in the areas assessed as (NS). 

After re-assessment occurs should it still be evident an overall understanding of this unit has not been demonstrated a meeting with your Educator will take place to discuss options for further/varied forms of assessment or repeating of the unit of competency at a cost.

Should additional support be required it is your responsibility to request additional assistance or clarification as soon as possible after receiving initial feedback.

?

“I affirm that all work submitted within is my true and original work unless otherwise credited”

Student signature:

Date:

?

If completing and submitting this assessment electronically, please tick this box to acknowledge that by including your name in place of a signature above, it is deemed to be your signature for the purpose of this assessment.

Total =

Name of Educator marking:

Moderated by:

Before commencing IV therapy, the attending nurse has to put into consideration a factors relating to the patient and the IV equipment. These aspects include ensuring that the Iv equipment is compatible with each other, the Iv solution has not expired, the Iv container is devoid of contamination and other mechanical issues like cracks, and adherence to the correct infection control in the infusion process. The nurse has to document all the management practices that the patient receives. It is important to note that the nurse is the primary caregiver to the patient ad is responsible for the patient during the whole infusion process (Catanyag, 2012).

There are different types of isotonic solutions that can be used for IV infusions. An example is normal saline which has 0.9 saline in water. One can also use a dextrose solution which has 5% dextrose and 0,225% saline.  The choice of Iv solution depends on patient factors and the solution available. When the patient needs both rehydration and glucose infusion, the best choice is dextrose solution (Rocha-e-Silva, 2016).

The prescribed infusion is to be carried out to ensure that 1000mls of fluid is administered to the patient in 6hrs. 1000mls/6hrs= 166.7mls of fluid per hour. One millimetre of water has about 20 drops. The number of drops per hour is calculated by multiplying the number of drops per millilitre of water by the number of millilitres infused in one hour. 166.7*20= 3334 drops. The number of drops per minute is 3334/60= 55.5 drops per minute. The rate of infusion will therefore be around 56 drops per minute (Härkänen, 2016).

Metoclopramide is the generic name of an antiemetic drug with several trade names including reglan, metoclopramide, and metozolv. The drug can be administered orally, intravenously or intramuscularly (Gaffigan, 2015). 

Metoclopramide is administered at the rate of 1 to 2grams and infused for more than fifteen minutes. The dosage has to be repeated every two hours for two doses followed by a three hour interval for three doses.

The dosage levels of metoclopramide used on a patient is dependent on the condition being treated. the cause of the nausea and vomiting determines the dosage forms to be used and the frequency.

Considering that the case scenario involves a patient with an intravenous line, the best way to administer the drug is by injecting it into the fluid being infused (McDowell, 2009).

To avoid possible drug interactions, the paracetamol medication can be administered orally since oral administration is equally effective (Fenlon, 2012).

The use of IV cannulas for infusion of fluids could easily lead to complications which make it necessary for the attending clinician to routinely monitor the infusion site and equipment. The direct access to the blood provided by the IV cannula can be a source of infection. Any Cannula that is not being used should be removed. The patient should also be educated, ensuring that they agree to the procedure. Always be on the look-out for infections. The cannula should also be well dressed at all times (Gillian, 2017).

An IV cannula check aims at preventing possible complications and ensuring that the process is going on as it should (Kim, 2017).

1. Correct insertion of the cannula into the vein should be ensured at all times, flashing the cannula can help ensure that the vein is correctly accessed. Adequate training ensures that few errors occurs during cannulation (Jones, 2014).

2. Correct dressing of the infusion site to ensure that the cannula is secured in place and avoid infection.

3. Absence of leakages is also an important aspect to check when checking the cannula.

4. The clinician has to make sure that the infusion process is painless. Pain is an indicator of venous phlebitis and is in most cases a sign that the cannula was not correctly inserted

Assessing the level of pain can be done using tools like the visual analogue scale and McGill pain questionnaire. The collection of a comprehensive history regarding the pain is essential to determine important aspects like the character, onset, and aggravating factors associated with the pain. Visual analogue scale is in most cases adequate to assess the level of pain. The patient will also be able to indicate the location of the pain in most cases (Gerbershagen, 2011).

The effectiveness of the medication used can be monitored using the main markers of the condition. Reduction or disappearance of the pain is the main marker that the medication works in most scenarios. Obvious discomfort normally visible in the patient will also disappear. In headaches whose intensity increase with certain environmental factors such as noise or light, the patient will show reduced sensitivity to these factors (Cowen, 2015).

Additional management of headaches include the avoidance of stress, the use of acupuncture techniques, dietary changes, aromatherapy, and massage. The management procedure used is highly dependent on the nature of the headache and the possible causes as evaluated by the clinician. Incorporating these management practices in the treatment of the patient can help eradicate the discomfort faster and more effectively.  Herbs can also be helpful in treating headaches. It is important to make sure that the herbs being used are compatible with the medication given to the patient to avoid possible drug toxicities.

Documentation of all aspects relating to the plain is essential to ensure that the whole team carries out their practices as expected. The documentation should be secured in the patient file for easier access when required. The most important aspects that need documentation include the nature of the pain before commencement of treatment, the treatment procedure being used, and the general appearance of the patient after the management procedure. Changes in management procedures should also be documented with important considerations being relayed from between the different clinicians involved in managing the patient (Jo Ann Dalton, 2001).

Paracetamol is a weak cyclooxygenase inhibitor and hence associated with less episodes of anaphylactic reactions. The signs of this reaction when present include facial and body edema, severe hypotension, and breathlessness. Breathlessness is caused by bronchospasms caused by the anaphylactic reaction. It is important to monitor the patient regularly and administer betamethasone and epinephrine which alleviate the symptoms preventing further complications of the anaphylactic attack. The clinician should establish if the patient has had previous attack due to paracetamol use before commencing with treatment (Stephenson., 2000)

1. The nurse has to discontinue the paracetamol infusion immediately. Making sure that the cause of the reaction is handled before commencing with the management of the resultant symptoms  forms the baseline of treatment.

2. The nurse should ensure that the patient is breathing. Mechanical breathing aids are important in this condition. The use of bronchodilators is also helpful in getting rid of the bronchoconstriction associated with anaphylaxis.

3. CVS resuscitation should be the next management practice. Handling the body edema associated with the disease is helpful in reversing the severe hypotension associated with the disease.

The main side effects of paracetamol use include increased heart rate, flushing, and allergic reactions which range from infusion site reactions to anaphylactic shock. The clinical manifestation of an adverse reaction is patient dependent and might be unique from patient to patient which has to be handled by making sure that the whole management team is vigilant on the patient condition before and after commencement of treatment.

The infusion of fluid subcutaneously is carried out when very small amounts of the fluid are to be infused; mostly 1ml or less. Only aqueous solutions should be used since suspensions cause tissue irritation and pain. The drugs being administered in the infusion have a decreased tissue penetration in subcutaneous administration and may show a more localized effect. The subcutaneous infusion of drugs will, however, show increased duration of action. The considerations in using subcutaneous drug administration should be the target organ, the patient’s preferences, the nature of the solution, and the desired duration of action.

CANNULATION DOCUMENTATION CHART

Affix patient sticky label

Visual Infusion Phlebitis Score

ACTION

I.V site appears healthy

  0

No sign of phlebitis

Continue to monitor and document once per shift  

? OBSERVE CANNULA      

One of the following is evident:

·    Slight pain near the I.V site or

·    Slight redness near the I.V site

  1

Possible first sign of phlebitis

Report to medical officer. Remove cannula and resite if required. Document in clinical record.

? OBSERVE CANNULA

Two of the following are evident:

  2

Early stage of phlebitis

Report to medical officer. Remove cannula and resite if required. Document in clinical record.

? RESITE CANNULA

·    Pale near I.V site

·   Erythema

·    Swelling

All of the following are evident

  3

Medium stage of phlebitis

Report to medical officer. Remove cannula and resite if required. Document in clinical record.

? RESITE CANNULA   ? CONSIDER TREATMENT

·    Pain along path of cannula

·    Erythema

·   Induration

All of the following are evident & extensive

  4

Advance stage of phlebitis or start of thrombophlebitis

Report to medical officer. Remove cannula and resite if required. Document in clinical record.

? RESITE CANNULA   ? CONSIDER TREATMENT

·    Pain along path of cannula

·  Induration

·    Erythema

·   Palpable venous cord

All of the following are evident and extensive

  5

Advanced stage of thrombophlebitis

Report to medical officer. Remove cannula and resite if required. Document in clinical record.

? INITIATE TREATMENT  ? RESITE CANNULA

·    Pain along path of cannula

·  Erythema

·    Palpable venous cord

·   Induration

·   Pyrexia

Check Site Once Per Shift

INSERTION

CHECKS

REMOVAL

Date

Time

Score

Initial

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: …………………………

Date……………………….

Time……………………….

Size………………………………………………………….

Time: …………………………

Site:

L

R (please circle)

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Inserted by…………………………………………………..

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: …………………..

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: ……………………………

Date……………………….

Size………………………………………………………….

Site:

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Time: …………………………..

Inserted by………………………………………………….

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………….

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: ……………………

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: ………………………………

Date……………………….

Size………………………………………………………….

Time: …………………………….

Site:

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Inserted by………………………………………………….

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: ………………………

Check Site Once Per Shift

INSERTION

CHECKS

REMOVAL

Date

Time

Score

Initial

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: …………………………

Date……………………….

Time……………………….

Size………………………………………………………….

Time: …………………………

Site:

L

R (please circle)

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Inserted by…………………………………………………..

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: …………………..

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: ……………………………

Date……………………….

Size………………………………………………………….

Site:

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Time: …………………………..

Inserted by………………………………………………….

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………….

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: ……………………

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: ………………………………

Date……………………….

Size………………………………………………………….

Time: …………………………….

Site:

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Inserted by………………………………………………….

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: ………………………

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: ………………………………

Date……………………….

Size………………………………………………………….

Time: …………………………….

Site:

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Inserted by………………………………………………….

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Signature: ……………………

Maximum time for other devices

as per MO Orders

Routine Change Due

Print name: ………………………

S/C / IV / CVC / PICC / Arterial /

Other……………………………………. (please circle)

Date: ………………………………

Date……………………….

Size………………………………………………………….

Site:

Time: …………………………….

Hand / Forearm / Cubital Fossa / Wrist /

Other…………………………………………………………

Signature: ……………………

Print name: ………………………

Inserted by………………………………………………….

Maximum time peripheral IV in situ 48 hrs

Maximum time for SC is 7 days

Maximum time for other devices

as per MO Orders

Routine Change Due

Attach ADR Sticker

AFFIX PATIENT IDENTIFICATION LABEL HERE

ALLERGIES & ADVERSE DRUG REACTIONS (ADR)

? Nil known ? Unknown (tick appropriate box or complete details below)

UR No. 521 344

Drug (or other)

Reaction/Type/Date

Initials

Family Name: SINCLAIR

Given Names: Joel

Date of birth: 8/11/2000

Sex ? M ? F

Sign CBennett

Print C. Bennett

Date 18/9/17

1^st prescriber to Print Patient Name and Check Label Correct:

……………………………………………..

Patient Weight (kg)………………

Height (cm)……………………

FACILITY / SERVICE: …………………………………

Medication Chart           of  

? IV Fluid

? BGL/ Insulin

? Acute Pain

? Other

Ward/Unit: …………………………

? Palliative Care

? Chemotherapy

? IV Heparin

ONCE ONLY, PRE-MEDICATION, TELEPHONE ORDERS & NURSE INITIATED MEDICINES

(Telephone orders MUST be signed within 24 hrs of order)

Date Prescribed

Medication

(Print Generic Name)

Route

Dose

Date/Time

Prescriber/Nurse Initiator (N)

Time Given

Pharmacy

18/9/17

Paracetamol

PR

Igm

0130

Medicines taken Prior to Presentation to Hospital (Prescribed, over the counter, complementary)

Own medications brought in? ? Y ? N

Administration aid? …………………. (Specify)

Medication

Dose & Frequency

Duration

Medication

Dose & Frequency

Duration

GP:

Community Pharmacy:

Documented by:                                           

(Sign)

(Date)

Medicines usually administered by:

AFFIX PATIENT IDENTIFICATION LABEL HERE

UR No:

Family Name:

Given Names:

Date of Birth:

Sex ? M ? F

1^st Prescriber to Print Patient Name and Check Label Correct: ………………….. Year 20 _______

Date

18/9/17

Medication (Print Generic Name)

Metoclopramide

Date

Prescriber’s Signature: ……………………… Print Name: ………………………….. Contact: ………………… Pharmacist: ………………….Date: …………….

Route

IV

Dose & Hourly Frequency

4/24

PRN

Max dose/24 hrs

6

Time

Indication

Nausea

Pharmacy

Dose

Route

Prescriber Signature

J.Johns

Print Name

J.Johns

Contact

22411

Sign

Date

Medication (Print Generic Name)

Date

Route

Dose & Hourly Frequency

PRN

Max dose/24 hrs

Time

Indication

Pharmacy

Dose

Route

Prescriber Signature

Print Name

Contact

Sign

Date

Medication (Print Generic Name)

Date

Route

Dose & Hourly Frequency

PRN

Max dose/24 hrs

Time

Indication

Pharmacy

Dose

Route

Prescriber Signature

Print Name

Contact

Sign

Date

Medication (Print Generic Name)

Date

Route

Dose & Hourly Frequency

PRN

Max dose/24 hrs

Time

Indication

Pharmacy

Dose

Route

Prescriber Signature

Print Name

Contact

Sign

Date

Medication (Print Generic Name)

Date

Route

Dose & Hourly Frequency

PRN

Max dose/24 hrs

Time

Indication

Pharmacy

Dose

Route

Prescriber Signature

Print Name

Contact

Sign

Date

Medication (Print Generic Name)

Date

Route

Dose & Hourly Frequency

PRN

Max dose/24 hrs

Time

Indication

Pharmacy

Dose

Route

Prescriber Signature

Print Name

Contact

Sign

Date

Medication (Print Generic Name)

Date

Route

Dose & Hourly Frequency

PRN

Max dose/24 hrs

Time

Indication

Pharmacy

Dose

Route

Prescriber Signature

Print Name

Contact

Sign

Date

Medication (Print Generic Name)

Date

Route

Dose & Hourly Frequency

PRN

Max dose/24 hrs

Time

Indication

Pharmacy

Dose

Route

Prescriber Signature

Print Name

Contact

Sign

Date

Medication (Print Generic Name)

Date

Route

Dose & Hourly Frequency

PRN

Max dose/24 hrs

Time

Indication

Pharmacy

Dose

Route

Prescriber Signature

Print Name

Contact

Sign

INTRAVENOUS

THERAPY ORDERS

MEDICATION SENSITIVITY?

YES      NO     If YES give details:

Affix patient identification label in this box

U.R. No: __521344____________________________________­­­_____________

Surname: _____SINCLAIR___________________________________________

Given Names: ___Joel__________________________­­­­­_____________________

D.O.B.: __8/11/2000________   Sex: _________M_______________________

Date

No.

TYPE OF FLUID

Order only one container per line.

Include strength.

Maximum order 24 hours.

Vol.

ADDITIVES

Only Drugs added to container.

ADMINISTRATION TIME

SIGNATURES

Hours

Start

Finish

Medical Officer’s

Registered Nurse’s

18/9/17

1

Isotonic Solution

1000Mls

NIL

6

0200

0800

J.Johns

J.Johns

INTRAVENOUS

THERAPY ORDERS

MEDICATION SENSITIVITY?

YES      NO     If YES give details:

Affix patient identification label in this box

U.R. No: __422611____________________________________­­­_____________

Surname: _____RAHAMA____________________________________________

Given Names: ___HASSAN__________________________­­­­­_________________

D.O.B.: __11/8/1958________   Sex: _________M_______________________

Date

No.

TYPE OF FLUID

Order only one container per line.

Include strength.

Maximum order 24 hours.

Vol.

ADDITIVES

Only Drugs added to container.

ADMINISTRATION TIME

SIGNATURES

Hours

Start

Finish

Medical Officer’s

Registered Nurse’s

18/9/17

1

Packed Cells

300Mls

NIL

4

1000

1400

Dr.J.Johns

Dr.J.Johns

18/9/17

N/Saline

100mls

NIL

15 mins

18/9/17

2

Packed Cells

300mls

NIL

4

1500

1900

Dr.J.Johns

Dr.J.Johns

18/9/17

N/Saline

100mls

NIL

15 mins