Just In Case Medication Chart - 2014 Page 3

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PATIENT NAME:__________________________________ DOB:_______________________________________________
24 HOUR SYRINGE PUMP
MEDICATION CHART
GOOD PRACTICE REQUIRES A PRESCRIBER REVIEW AFTER 3 DAYS.
1. As diluent generally use water for injections.
2. On some occasions 0.9% Sodium Chloride is the diluent. This information is available in the
DILUENT
local ambulatory syringe pump policy.*
3. Use diluent to make up total volume to 18mL (in a 20ml syringe) or 23.5ml (in a 30ml
syringe) as per ambulatory syringe pump policy.
SYRINGE PUMP DRUG
Refer to local ambulatory syringe pump policy for stability information when mixing TWO or
COMPATIBILITY CHARTS
THREE drug combinations.
If prescribing FOUR DRUGS in a single syringe pump there is a high risk of incompatibility. Advice is available
from the specialist palliative care team.
PRESCRIBERS SIGNATURE
DATE
TIME
MEDICINE ADDED TO SYRINGE PUMP
DILUENT
ROUTE
APPROVED NAME
DOSE
PRESCRIBER TO STATE AND INITIAL THE
S/C
REASON FOR THE SYRINGE PUMP
EOL Care
Initials
Symptom
Initials
Management
BATTERY
STOP
SITE
SITE
LEVEL
START
START
DATE
TIME
DOSE GIVEN
GIVEN/CHECKED BY
POSITION
CONDITION
(CHANGE IF
RATE
VOLUME
DATE
TIME
<40%)
* Local ambulatory syringe pump policy available at:
Jersey Hospice Care
Family Nursing and Home Care
Central filing
HSS Net

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