Adult Ambulatory Infusion Order Form - Cho Intravenous Immune Globulin (Ivig) Page 3

Oregon Health & Science University

Hospital and Clinics Provider’s Orders

ACCOUNT NO.

ADULT AMBULATORY INFUSION ORDER

MED. REC. NO.

CHO:INTRAVENOUS IMMUNE

NAME

GLOBULIN (IVIG)

BIRTHDATE

Page 3 of 4

Patient Identification

ALL ORDERS MUST BE MARKED IN INK WITH A CHECKMARK (  ) TO BE ACTIVE.

HYPERSENSITIVITY MEDICATIONS:

1. DiphenhydrAMINE 25 mg IV, AS NEEDED x2 doses (Max dose : 50 mg) for hypersensitivity

reaction

2. EPINEPHrine 0.3 mg IM, AS NEEDED x1 dose for hypersensitivity reaction

3. Hydrocortisone 100 mg IV, AS NEEDED x 1 dose for hypersensitivity reaction

4. Nursing communication order, every visit: Please follow treatment algorithm for acute infusion

reaction. Algorithm is located in the OHSU Policy Management System.

AS NEEDED MEDICATIONS:

1. Acetaminophen 650 mg oral, EVERY 4 HOURS AS NEEDED for fever

2. Meperidine 25 -50 mg IV, EVERY 2 HOURS AS NEEDED (NTE 50 mg/hr) for rigors in the absence

of hypotension

-8064

ONLINE 06/2015 [supersedes 07/2014]

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Parent category: Medical