Nurse Visit Note

Date of Infusion:

Assessment

Therapy:
IVIGFactorABXOther

Via:
PumpGravity

Pump Type:

# of Attempts:

Reason for Visit

AssessmentInstructionIV RestartPort AccessLine CareMedication AdminLab DrawDressing ChangeOther

Access Device

PeripheralCVCVADPICCMidlineS.Q.

Flushed With:

Comments:

Meds Given:

Lab Draws

Peripheral SiteLine DrawLab in a BoxOther

Site:

Diagnostics:

System Assessments

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary:

Neuro/Muscular/Skeletal:

Psych/Social:

Skin:

Endocrine/Reproductive:

Vital Signs

BP:

Pulse:

Respiration:

Temperature:

Height:

Weight:

Dressing Change

PICC/MidlineBlood Return: Yes/No/N/A

Upper Arm Circumference (cm):

External Catheter Length (cm):

Was Order Verified?Was Length of Line Confirmed?

Catheter Length Removed (cm):

Patient Tolerance of Line D/C:

Additional Comments

Additional Comments:

Education Provided

Education Topic 1:
HydrationNutritionWound CareOther

Verbalized UnderstandingDemonstrated UnderstandingAdditional Reinforcement Needed

Education Topic 2:
HydrationNutritionWound CareOther

Verbalized UnderstandingDemonstrated UnderstandingAdditional Reinforcement Needed

Education Topic 3:
HydrationNutritionWound CareOther

Verbalized UnderstandingDemonstrated UnderstandingAdditional Reinforcement Needed

Progress Notes

Progress Notes/Concerns:

MD/Care Team Communication:

Reason for Delay (if any):

MD Notification:
YesNo

Nurse Details

Nurse Signature:

Nurse Name (Printed):

Nurse License #:

Next Visit: