York Hospital York, Pa Physician'S Treatment Record Parenteral Iron Dextran Standing Orders
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1
2NURSING
SERVICE
DATE
TIME
ORDER
SIGNATURE
Allergies:
Height ____________
Weight_________ lb / kg
IBW ____________kg
Hgb __________ g/dl
Hct __________ %
1. If patient has history of anaphylactic or other serious reaction to iron
dextran, do not administer
2. Calculate Ideal Body Weight (IBW):
IBW (male) = 50 kg + (2.3 x height in inches over 5 feet)
IBW (female) = 45.5 kg + (2.3 x height in inches over 5 feet)
Check patient’s baseline vial signs (blood pressure, pulse, respiratory rate,
3.
and temperature)
4. Determine number of milliliters of iron dextran desired based upon indication:
a. Iron Deficiency Anemia (See dosing chart #1 on reverse)
Total volume of iron dextran required: ________ ml (50 mg/ml)
Administer total volume of iron dextran IV in 250 ml normal saline x 1
over 4 hours (Maximum rate of 6 mg/minute)
b. Iron Replacement for Blood Loss (See dosing chart #2 on reverse)
Total volume of iron dextran required: _______ ml (50 mg/ml)
Administer total volume of iron dextran IV in 250 ml normal saline x 1
over 4 hours (Maximum rate of 6 mg/minute)
5. Administer 25 mg (0.5 ml) test dose of iron dextran IV in 100 ml normal
saline over 5-10 minutes
6. Observe patient for at least one hour following the test dose, taking vital
signs Q 5 minutes x 3, then Q 15 minutes x 3
7. Consider premedication 30 minutes prior to infusion with:
Acetaminophen 650 mg PO/PR x 1
Diphenhydramine 25 mg PO/IV x 1
8. After one hour of observation, begin IV infusion
9. During IV infusion, check patient’s vital signs (blood pressure, pulse,
respiratory rate, and temperature) Q 15 minutes x 1 hour, then Q 30
minutes until the end of the infusion
Physician’s Signature:
YORK HOSPITAL
YORK, PA
PLACE LABEL HERE
PHYSICIAN’S TREATMENT RECORD
PARENTERAL IRON DEXTRAN
STANDING ORDERS
Form 5249-IRON DEXTRAN 11/02
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