IVIG FLOW SHEET - TherapyOM

1 ivig FLOW SHEET Form#: CLIN-048C Effective Date: 7/1/12 Approved By: VP of Clinical Operations Revised Date: N/A Karen B. Spano, RPh Patient Name: _____Date: _____ This form is to be used in conjunction with the Nursing Visit Assessment Report Premeds: N/A Yes Time pre-meds given: _____ Medications given: Diphenhydramine _____mg PO IV Acetaminophen _____mg PO Other route: _____ Prednisone _____ mg PO Other: _____PO IV ivig : Brand_____ Dose.

2 _____ grams in _____mls IV to infuse over _____hours via Gravity R egulator ( dial-a-flow) Pump (model): _____ every (enter frequency) _____ Diluent As Provided by Manufacture: Yes NO If no, diluent used: _____ Lot number _____ Expiration Date: _____ Lot Number _____ Expiration Date: _____ Lot number _____ Expiration Date: _____ Lot Number _____ Expiration Date: _____ Administration and patient monitoring for ivig (pre-infusion, every 15 minutes for first hour, hourly during infusion, and post infusion) TIME TEMP PULSE RESP B/P RATE ML/HR GTTS/MN IV PATENT Y = YES N = NO S/S ADVERSE REACTION Y = YES N = NO COMMENTS Clinical Notes: _____ _____ Clinician s Signature: _____ Date: _____ Reviewed By: _____ Date: _____ ____