Outpatient IV Antibiotic Order Form

Patient Name:

Date of Birth:

Weight (in lbs and kgs):

Height (inches; ft and cm if possible):

Describe/confirm IV Access:

PICC line placement ordered?

Where placed?

Who is dressing the site?

Who is monitoring the site?

Add Another Diagnoses

Add Another Medication

Alteplase 2mg IV to declot central IV access per Infusion Solutions protocol as needed for occlusion.
Flush line with D5W, 0.9% NaCl and/or Heparin 10 units/ml or 100 units/ml per Infusion Solutions protocol.
Lidocaine 1% - up to 0.2ml intradermally PRN (may buffer with sodium bicarbonate 8.4% in 10:1 ratio).
Infusion Reaction Management per Infusion Solutions protocol as needed.

Last Dose in Hospital:

Date:

Time:

First Dose in Home:

Date:

Time:

Clinical Pharmacy orders for Drug level monitoring:

Vancomycin levels?

Gentamicin levels?

Immunosupressant levels?

Nursing Orders:

LINE:

Peripheral Line

Central Line/Port

Line Flush

Standard Flush Protocol

** This standard Flush Protocol is for ADULTS only. MD/NP must complete specific flush protocol below for any paediatric clients on IV therapy.

Peripheral

Type of pm Adaptor: Positive Pressure Device (PPD)
Pre-Infusion Flush: 3 cc NS
Maintenance Flush: 3 cc NS q 24 hours
Pre and Post Blood Drawing: N/A
Pre and Post Intermittent TPN
Flushing Protocol for Continuous Infusion Pumps: Change site q72 hours

Ex-Dwell/Midline

Type of pm Adaptor: (PPD)
Pre-Infusion Flush: 10 cc NS
Maintenance Flush: 10 cc NS q 24 hours
Pre and Post Blood Drawing: N/A
Pre and Post Intermittent TPN: N/A
Flushing Protocol for Continuous Infusion Pumps: Flush with 10 cc NS with each tubing change

Tunneled Catheter (ex. Hickman)

Type of pm Adaptor: PPD
Pre-Infusion Flush: 10 cc NS
Maintenance Flush: 10 cc NS Weekly
Pre and Post Blood Drawing: Pre: 20 cc NS. Post: 20 cc NS
Pre and Post Intermittent TPN: Pre: 20 cc NS. Post: 20 cc NS
Flushing Protocol for Continuous Infusion Pumps: Flush with 10 cc NS with each tubing change

Valved PICC Line (ex. Groshong)

Open-ended PICC Line (not Groshong)

Implanted Port

Type of pm Adaptor: N/A
Pre-Infusion Flush: 10 cc NS followed by 5cc 100 U/ml hepalean
Maintenance Flush: 10 cc NS followed by 5 cc 100 U/ml hepalean q 4 weeks
Pre and Post Blood Drawing: Pre: 20 cc NS. Post: 20 cc NS followed by 5 cc 100 U/ml hepalean
Pre and Post Intermittent TPN: Pre: 20 cc NS. Post: 20 cc NS followed by 5 cc 100 U/ml hepalean
Flushing Protocol for Continuous Infusion Pumps: Flush with 10 cc NS with each tubing change

Specific Flush Protocol

Specify:

Add Another Antibiotic

Labs:

CBC with Diff

weekly

every ___

If every, please specify

ESR (Erythrocyte Sedimentation Rate)

weekly

every ___

If every, please specify

Serum Creatinine

weekly

every ___

If every, please specify

ALT

weekly

every ___

If every, please specify

CRP

weekly

every ___

If every, please specify

CK (for Daptomycin)

weekly

every ___

If every, please specify

BMP (Na, K, Cl, CO2, BUN, SCr, Gluc, Ca)

weekly

every ___

If every, please specify

CMP (DMP + AST, ALT, TP, Alb, Glob, Alp, Tbil)

weekly

every ___

If every, please specify

Hepatic Panel (Alk Phos, Alb, DBil, Tbil, TP, ALT, AST)

weekly

every ___

If every, please specify

Other

weekly

every ___

If every, please specify

If Other, please specify:

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Date

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Date:

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