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Ketamine Intravenous Infusion
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IV Placement
• • •
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Preoperative Diagnosis
• • •
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Ketamine Amount
• • •
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Saline IV Bag Used
• • •
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Added to IV
• • •
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Lot #
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BUD/Expiration Date:
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Lot #
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BUD/Expiration Date:
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Comments
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Estimated time of IV placement
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Gauge of Needle
• • •
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Location of IV site
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Number of Attempts
• • •
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Expiration Dates Checked
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IV Drip Rate
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Pre IV Vitals
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BP
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Pulse
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Temperature
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%O2
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Respiration Rate
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Start Time
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Patient Instructed to Limit Movement
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15 Minutes into IV Vitals
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BP
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Pulse
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Temperature
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%O2
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Respiration Rate
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30 Minutes into IV Vitals
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BP
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Pulse
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Temperature
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%O2
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Respiration Rate
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45 Minutes into IV Vitals
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BP
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Pulse
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Temperature
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%O2
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Respiration Rate
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60 Minutes into IV Vitals
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BP
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Pulse
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Temperature
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%O2
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Respiration Rate
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Timing of additions/pushes
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End Time
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Assessment of Insertion Site
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Post IV Vitals
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BP
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Pulse
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Temperature
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%O2
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Respiration Rate
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Pre-procedure Pain Assessment
/
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Post-procedure Pain Assessment
/
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Depression/PTSD Assessment
/
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Comments about severity of Depression/Anxiety/PTSD
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Improvement in Other Measures
• • •
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Patient Instructions Post IV
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Complications
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Patient Satisfaction
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Anticipated Repeat Infusion
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Return visit scheduled
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Stable Upon Discharge
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Discharge Instructions
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