Immune Globulin Infusion Therapy Plan Orders Page 2


Name: ______________________________________
Immune Globulin (Gammagard Liquid) - IVIG
Group Health Member I.D. # ____________________
Infusion Therapy Plan Orders
Page 2 of 2
Date of Birth ________________________________
IV Line Care
dextrose 5% infusion (D5W) 250 mL
Rate: 30 mL/hr Route: Intravenous
Frequency: Run continuously to keep vein open
Start peripheral IV if no central line
heparin flush 100 unit/mL
Dose: 500 units Route: Intracatheter
Frequency: PRN for IV line care per Nursing Policy
Infusion Reaction Meds
albuterol (PROVENTIL) nebulizer solution 0.083%
Dose: 2.5 mg
Route: Nebulization
Frequency: PRN for shortness of breath/wheezing
diphenhydrAMINE (BENADRYL) injectable
Dose: 25 mg
Route: Intravenous
Frequency: Once PRN, May repeat x1 for urticaria, pruritis, shortness of breath. May repeat in 15 minutes if
symptoms not resolved.
EPINEPHrine 1 mg/mL (1:1000) injectable
Dose: 0.3 mg
Route: Intramuscular
Frequency: Once PRN for anaphylaxis. Notify physician if administered.
hydrocortisone sodium succinate (SOLU-CORTEF) injectable
Dose: 100 mg
Route: Intravenous
Frequency: Once PRN for hypersensitivity
Lab Review for Nursing
Ensure baseline lab (e.g. SCr) is drawn within 3 months of initial treatment if providers have ordered.
Nursing Orders
• Weight should be recorded at least every 6 months or more frequently as appropriate. Notify physician if
weight has changed 10% or greater from baseline.
• If infusion-related reaction, 1) STOP infusion immediately; 2) Increase primary infusion to wide open rate; 3)
Administer PRN medications per hypersensitivity protocol; 4) Notify MD
• Stop infusion and report these signs of adverse effects to provider and/or call the code team immediately: 1)
Transfusion-related acute lung injury (TRALI): severe respiratory distress, pulmonary edema, hypoxemia, fever
in the presence of normal left ventricular function, sudden development of dyspnea, and hypotension
• Discontinue IV line when therapy complete and patient stabilized.
GAMMAGARD Prescribing Information Revised June 2012.
Group Health Nursing Protocol - IV Immune Globulin
Group Health Infusion Locations
Bellevue Medical Center
Riverfront Medical Center – Spokane
11511 NE 10
St, Bellevue, WA 98004
W 322 North River Drive, Spokane, WA 99201
Fax: 425-502-3512
Phone: 425-502-3510
Fax: 509-324-7168
Phone: 509-241-2073
Capitol Hill Medical Center
Silverdale Medical Center
201 16
Ave E, Seattle WA 98112
10452 Silverdale Way NW, Silverdale, WA 98383
Fax: 206-326-2104
Phone: 206-326-3109
Fax: 360-307-7493
Phone: 360-307-7444
Everett Medical Center
Tacoma Medical Center
2930 Maple St, Everett, WA 98201
209 Martin Luther King Jr Way, Tacoma, WA 98405
Fax: 425-261-1659
Phone: 425-261-1681
Fax: 253-383-6262
Phone: 253-596-3666
Olympia Medical Center
700 Lily Road N.E., Olympia, WA 98506
Fax: 360-923-7106
Phone: 360-923-7164
Provider Signature: ____________________________________________ Date: _______________
Printed Name: ______________________________________ Phone: ___________ Fax: ___________
Revision Date: 9/30/2015 Group Health Cooperative <Reference#115112>


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