Energy Inspired Wellness

Order Set

Full Name *

Email *

Allergies *

Informed Consent Completed?

Medical History Reviewed?

Active Good Faith Exam On File?

Blood Pressure

Heart Rate

Respiratory Rate

O2 Sat%

Temperature

Any Pre-Infusion lab work required? If so, please state what and values, otherwise state none

IV Fluid Base

Normal Saline

Lactated Ringers

IV Fluid Base Volume

250cc

500cc

1000cc

IV Gauge

IV Location

Choose The Formula

Add-On Boosters Select if Any

IM Injections Select if Any

Additional Orders if Any

Stop Infusion Immediately and Call Provider if:

--> Patient displays any adverse reaction signs or symptoms or any complaints of pain or discomfort
--> Client’s request to stop
--> Condition of client indicates calling 911

Discharge

-> Client is able to leave without further care if VS are stable and able to ambulate
-> Remove IV prior to discharge
-> Apply Pressure for 2 minutes after removal
-> IV dressing can be removed after 10 minutes
-> Give Client Discharge instruction sheet

Orders *

I verify the order was given in accordance to what has been approved by the medical director

Infusion Start Time *

Infusionist Name *