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Subjective (Pre-Infusion #1)
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Contraindication Screening
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Patient Denies (Select ALL)
• • •
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Pre-Infusion Vital Signs
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Pre-Infusion Blood Pressure
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Pre-Infusion Pulse
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Pre-Infusion SP02
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Pre-Infusion Respiration Rate
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Pre-Infusion Lung Sounds
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Lung Sounds OTHER
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Weight
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Temp
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IV Catheter Placement
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Catheter Size
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Location
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Attempts
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Tubing Set
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Bag #1
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Time of initial Spike / Access (Use 24 hour clock)
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Type of Fluids #1
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IV Start Time #1 (Use 24 hour clock)
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Additives
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Myers Cocktail
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Myers Plus
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Immune
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Immune Plus
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Performance Plus
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Additive
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Additive DOSE ex: 200mg = 200
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Measurement
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Route Administered
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Additive
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Additive DOSE ex: 200mg = 200
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Measurement
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Route Administered
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Additive
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Additive DOSE ex: 200mg = 200
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Measurement
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Route Administered
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Additive
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Additive DOSE ex: 200mg = 200
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Measurement
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Route Administered
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Additive
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Additive DOSE ex: 200mg = 200
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Measurement
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Route Administered
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Additive
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Additive DOSE ex: 200mg = 200
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Measurement
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Route Administered
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Additive
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Additive DOSE ex: 200mg = 200
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Measurement
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Route Administered
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Additive
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Additive DOSE ex: 200mg = 200
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Measurement
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Route Administered
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Medications
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Medication
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Medication DOSE ex: 15mg = 15
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Measurement
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Route Administered
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Medication
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Medication DOSE ex: 15mg = 15
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Measurement
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Route Administered
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Medication
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Medication DOSE ex: 15mg = 15
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Measurement
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Route Administered
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Medication
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Medication DOSE ex: 15mg = 15
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Measurement
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Route Administered
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Medication
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Medication DOSE ex: 15mg = 15
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Measurement
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Route Administered
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Subjective (During-Infusion Bag #1)
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Post Infusion Bag #1
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IV Stop Time
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Volume Infused #1 ONLY THE NUMBER
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Post-Infusion Vital Signs
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Post-Infusion Blood Pressure
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Post-Infusion Pulse
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Post-Infusion SP02
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Post-Infusion Respiration Rate
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Post-Infusion Lung Sounds
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Lung Sounds OTHER
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Subjective (Post-Infusion Bag #1)
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