Adult Ambulatory Infusion Order Form - Cho Intravenous Immune Globulin (Ivig) Page 2
ADVERTISEMENT
1
2
3
4Oregon Health & Science University
Hospital and Clinics Provider’s Orders
ACCOUNT NO.
ADULT AMBULATORY INFUSION ORDER
MED. REC. NO.
NAME
CHO:INTRAVENOUS IMMUNE
GLOBULIN (IVIG)
BIRTHDATE
Page 2 of 4
Patient Identification
ALL ORDERS MUST BE MARKED IN INK WITH A CHECKMARK ( ) TO BE ACTIVE.
MEDICATIONS: (must check one)
**DO NOT delete alternate brand when placing electronic
order, pharmacy will delete**
Gammagard 10% (default brand):
(Pharmacist will round dose to nearest 5 gram vial and modify brand selection based upon availability
during order verification)
Intravenous Immune Globulin (IVIG) 200 mg/kg = ______ mg IV, ONCE
Intravenous Immune Globulin (IVIG) 400 mg/kg = ______ mg IV, ONCE
Intravenous Immune Globulin (IVIG) 500 mg/kg = ______ mg IV, ONCE
Intravenous Immune Globulin (IVIG) 1 gram/kg = ______ grams IV, ONCE
Intravenous Immune Globulin (IVIG) ___________ grams IV, ONCE
Interval: (must check one)
Once
Daily x ____ doses
Every ____ weeks for ____ doses
Specifications:
Patient requires a specific brand of IVIG (other than those listed above)
Please specify here: _____________________________________
Patient requires IVIG at a 5% concentration
Infuse per protocol. Decrease rate of infusion in patients who may be at risk of renal failure.
Filtration is not necessary. Pharmacy will filter all preparations if required.
NURSING ORDERS (TREATMENT PARAMETERS):
1. Vital signs, every visit: Assess vital signs before initiating IVIG infusion. During the first two
infusions: assess vital signs at 15 minutes, 30 minutes, 1 hour, and then hourly for remainder of
infusion. For subsequent infusions: if the patient has been stable without adverse reactions, the
frequency of vital signs is discretionary.
2. Nursing communication order, every visit: IVIG Infusion Guidelines are available on the OHSU
Pharmacy Services Intranet. See below for Infusion Guidelines. The rate of infusion may be
increase only if no adverse reactions occur.
3. Nursing communication order, every visit: Manage line per OHSU Vascular Access Flushing
Procedure # HC-NSG-236-PRO (Could include flushes with D5W, NS, heparin 10 units/mL,
heparin units/mL ,or t-PA 2 mg/2mL)
4. Nursing communication order, every visit: Manage central venous catheter per OHSU De-clotting
Procedure for Vascular Access Policy # HC-NSG-126-POL
5. Nursing communication order, every visit: Manage site access per OHSU PICC and Central
Venous Access Site Assessment and Dressing Changes Policy # HC-NSG-189-POL
PO
-8064
ONLINE 06/2015 [supersedes 07/2014]
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical