Full Order Set

Full Name *

Email *

Allergies *

Informed Consent Completed? *

Medical History Reviewed? *

Yes

IV Access: Insert peripheral IV Catheter 20g or 22g. Assess IV site at 15 min, 30 min, and at the completion of the infusion.

Administer IV Fluids:

Sodium Chloride (0.9%) Normal

Lactated Ringers

Stop Infusion Immediately and Call Provider if:

--> Patient displays any adverse reaction signs or symptoms or any complaints of pain or discomfort
--> Client’s request to stop
--> Condition of client indicates calling 911

Discharge

-> Client is able to leave without further care if VS are stable and able to ambulate
-> Remove IV prior to discharge
-> Apply Pressure for 2 minutes after removal
-> IV dressing can be removed after 10 minutes
-> Give Client Discharge instruction sheet

Pre-Infusion Vital Signs *

Any Pre-Infusion lab work required? If so, please state what and values. If not, please state no. *

Venous Access: *

Site of injection: *

Route: *

IV Fluid Base: *

Normal Saline

Lactated Ringers

IV Fluid Base Volume: *

250cc

500cc

1000cc

IV Infusion Mixture *

Add-On Boosters Select if Any

IM Injections Select if Any

Additional Orders if Any

IV Removal *

Time Infusion Completed: *

Post-Infusion Vital Signs: *

Clinical Notes (Good Faith Exam) *

Provider’s Name *

Provider’s Signature *

Date Signed (Order Set) *