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IV Nurse/Medic Name
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Your Name Here
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Patient Condition Before IV -
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All boxes must apply to administer IV
• • •
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Blood Pressure -
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Systolic/Diastolic
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Initial Respiratory Rate -
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Must be between 12-20 breaths/min
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Initial Heart Rate -
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Record Heart Rate
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IV Insertion Time -
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Time of successful IV insertion/placement. Record any failed attempts/ location of failed attempts.
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Start Time of IV Infusion -
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Enter Start Time
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IV Infusion Ordered -
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Select IV Infusion Ordered
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Add-Ons Ordered -
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Select all that Apply
• • •
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IV Stop Time -
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Enter Stop Time
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Did patient receive the full IV?
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Yes / No
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If no, how much did they receive?
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Approx. Milliliters Received
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Catheter intact after removal?
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Yes / No
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Bleeding Controlled with bandage after removal?
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Yes / No
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Patient Condition After IV
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Select all that Apply
• • •
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Discharge Blood Pressure -
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Systolic/Diastolic
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Discharge Heart Rate -
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Record Heart Rate
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Discharge - Respiratory Rate
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Record Respiratory Rate
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Additional Notes
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Enter ANYTHING Relevant
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Additional Notes (Cont'd)
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Enter ANYTHING Relevant
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