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Patient presents for IV therapy
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Contraindications of IV nutritional therapy
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Heart disease?
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Pulmonary hypertension?
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Kidney disease?
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Is patient on dialysis?
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Any other volume overload condition?
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G6PD (glucose-6-phosphate dehydrogenase) deficiency?
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If female, pregnant/possibly pregnant?
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Fainting with needles/shots?
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Physical Examination
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General Normal
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General Abnormal
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HEENT Normal
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HEENT Abnormal
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Cardiovascular Normal
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Cardiovascular Abnormal
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Repiratory Normal
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Respiratory Abnormal
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Neurological Normal
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Neurological Abnormal
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ALLERGIES
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ALLERGIES (OTHER)
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MEDICAL CLEARANCE FOR IV NUTRIENT THERAPY
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MD ORDER
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IV PREPARED BY:
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FLUID BASE
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INFUSION
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Other infusion given
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NDC
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Lot Number
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Expiration/Best Use Date (BUD)
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BOOSTER
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Other booster(s) given
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NDC
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Lot Number
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Expiration/Best Use Date (BUD)
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IV STARTED BY:
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CATHETER SIZE
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Other catheter size given
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SITE OF IV
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Other site
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NUMBER OF ATTEMPTS
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NUMBER OF ATTEMPTS (other)
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Was IV line placement successful?
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TIME IV STARTED (mm:hh)
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INITIAL VITAL SIGNS (Temp, BP, pulse)
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TIME IV STOPPED (mm:hh)
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ENDING BLOOD PRESSURE (mmHg)
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ENDING PULSE (bpm)
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ENDING TEMPERATURE (F)
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INFUSION NOTE
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ADDITIONAL INFUSION COMMENTS
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IV DISCHARGE NOTE
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ADDITIONAL DISCHARGE COMMENTS
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