Medication Worksheet

Patient has infusing IV fluid

Solution/Rate Ordered

Fall2011 Special Medications Patient has a PCA

Intravenous or epidural? Medication concentration: (Orders) Basal (continuous) rate: Bolus dose: Lockout interval: Max # bolus/hour: Max dose in 4 hours: Why is this person getting a PCA?

NaCl 0.9%/125 mL/hr Continuous

Type VAD

Peripheral (Right; Antecubital 20)

Tonicity (anticipated effect on patient)

Replacement in deficiency states and maintenance of homeostatis. Helps maintain water distribution, fluid and electrolyte balance, acid-base equilibrium, and osmotic pressure.
Why is this person getting this fluid (address all IV components)

Hydration. Maintenance and replacement of fluid and electrolyte status.

When will the IV be discontinued? Change to SL?

Unknown
Time/date last bag hung:

When will the PCA be discontinued?

Unknown
Time/date last tubing change:

Time/date last rate change: Time/date bag/syringe last changed:

Pharmacokinetics (onset, peak, duration, metabolism)

Patient has only had an IV since admission on 10/6/11; I cared for patient on 10/7/11, most likely patient has not had a tubing change yet.
Time/date IV site started/dressing changed:

Unknown/10-6-11/Afternoon on 10/7/11
(For any additives to IV solution) Adverse Reaction: Common:

Textbook Dose Range Contraindications/Cautious use Adverse Reaction: Common: Severe: Toxicity signs/Overdose & Antidote? Administration Parameters (compatibility, dilution) Assessment needed:

No symptoms
Severe:

CHF and Pulmonary Edema

Toxicity signs/Overdose & Antidote?

No symptoms/No antidote

Assessments needed:

Assess fluid balance (intake and output, daily weight, edema, lung sounds) throughout therapy. Assess pt. for symptoms of hyponatremia (H/A,

tachycardia, lassitude, dry mucous membranes, N&V, muscle cramps) or hypernatremia (edema, weight gain, hypertension, tachycardia, fever, flushed skin, mental irritability) throughout therapy. Lab Tests: Monitor serum sodium, potassium, bicarbonate, and chloride concentrations and acid-base balance periodically for pt. receiving prolonged therapy with sodium chloride. Monitor serum osmolarity in pt. receiving hypertonic saline solutions. Reference(s): Davis Drug Guide, 12th Edition, pp. 1161-63

Reference(s):

Medication Worksheet
Patient has corrective insulin
Insulin name (generic/trade): Type: Frequency ordered: for Blood Glucose of: Hypoglycemia protocol? Call MD for blood glucose over.? Able to change protocol level? Pharmacokinetics (onset, peak, duration, metabolism) Adverse Reaction: Common: Severe: Toxicity signs/Overdose & Antidote? Past 24 hours glucose & insulin date/time blood glucose: Medication at home? Dose or med change? Reference(s): Give x insulin: units

Fall2011

Patient has an electrolyte protocol

Which electrolyte:

Why is this person on this protocol Home Medication Yes/No, Pharmacokinetics (onset, peak, duration, metabolism) Textbook Dose Range (for ordered route and indication) Contraindications/Cautious use Date/Time: . Adverse Reaction: Common: Last serum level:

Severe:

Toxicity signs/Overdose & Antidote?

insulin received:

Administration Parameters oral/enteral (empty stomach, with food) Parenteral (compatibility, dilution required and rate)

Assessment needed (pre, during and post)

Reference(s):