IOC RECERT

IOC RECERT
COMPREHENSIVE NURSING ASSESSMENT
Pharmacy:
Immuno/Biologic/Blood Component Therapy
Visit type:*

Start of care (SOC)RecertificationResumption of CareTransfer of care (TOC)
Date of visit:

MonthDayYear
Date
Patient information
Patient Name:*
Patient Signature:

Clear
Sex*

MaleFemale
Day: 1 of
DOB:

MonthDayYear
Date
Allergies*

NKAKnown (list)
List of Allergies
Others Allergies
Lives in*

Private residenceNursing homeOther
Lives*

AloneWith
Religious considerations: Impacts care?*

NoYes:
Pet
Diagnosis
Primary:*
Secondary:
Therapy*

IVIGSCIGSoluMedrolRemicade/entyvioRituxanAlpha 1Enzyme replacementOther
Pertinent Medical History
Environmental Safety
Environment safe for services:

YesNo
Problem:*

UncleanPestsDangerous neighborhoodNo heatNo phoneNo electricityNo 3 prong outletNo running waterOther (specify)
Psychosocial
WNL
Support system      No support system
Sleep problems AnxiousDepressed Mood swings
Evidence of abuse/neglect   Ineffective coping
Other:*
Baseline Vital Signs
B/P:* /*
Temp:* A 0 E R T*
Pulse:*RegularIrregular*
Resp:* RegularIrregular*
Weight:* * ActualState*
Neurological/mental status
WNL
Alert/Oriented x Confused
Lethargic ParesthesiaTremors
Seizures AphasiaMemory loss
Headache
Slurred speech Vertigo Hemiplegic
ParaplegicShuffling gait
Development:
No problem noted
Developmentally delayed*
Cardiovascular
WNL
Rhythm: RegularIrregularPalpitations
Symptoms:   TachycardiaBradycardia
A-Fib   Angina   SOB      Edema, non-pitting
Edema, pitting1+2+ 3+ 4+*
Location:
Skin
WNL
Color: PaleFlushedCyanoticJaundice Mottled
Integrity: Warm, dry, intactRashScars LesionsBruisesPetechiaeScleroticMassWoundDrainage*
Comment:
Respiratory
WNL
Breath Sounds:
Clear         WheezesCrackles   Rhonchi   SOB   Dyspnea
Rhythm:
Eupneic   Labored/Retractions
Cough:
Productive   Non-productive
Sputum color:
Respiratory medical equipment
O2: l/minContinuous   PRN   Nighttime only   C-PAP or equivalent at night*
Eyes
WNL
Check all that apply:
PERRLA Unequal pupilBlurred vision Photophobia Lesions Jaundice Drainage Redness ItchingBlind Glasses Contacts*
Ears
WNL
DrainagePainTinnitus
Uncorrected deafness/hearing impaired
Hearing aid:Right   Left   Both
Cochlear implant:Right   Left   Both*
Nose
WNL
Loss of smell Post-nasal drip Congestion
Epistaxis
Drainage*
- Color:
- Consistency:
Mouth/Throat
WNL
Dysphagia HoarsenessLesions
Poor dentition*
Nutrition
Diet: Non-compliant
Appetite: Good Fair Poor*
Weight loss/gain: (amt)
Intended Unintended
Fluid Intake: #Liters/day: *
Fluid restrictions: ml/24 hrs.
Chokes on fluid   Difficulty swallowing
Dry cracked lips   Oral lesions
Enteral feeding   Inability to prepare food
COMPREHENSIVE NURSING ASSESSMENT (CONTINUED)
G.I.
WNL
Bowel sounds:
Normal         HyperactiveHypoactive
Symptoms:
Nausea   Vomiting   Diarrhea   Lesions   Constipation   Candidiasis   Stomatitis   Incontinence
Abdomen:  Soft   Firm   Distended*
Last bowel movement:   *
G.U.
WNL
Change in urine color:NoYes
Urine color:ClearCloudyYellowAmberRusty
Symptoms:
Dx: UTI
RetentionBurningOdorFrequency
AnuriaIncontinence
Foley*
Musculoskeletal
WNL
MAE Impaired ROM: UE LE
Unsteady gait >
Abnormalities/weakness:

Activities limitation:*
Pain
WNL
Intensity: (scale: 1-10)
Duration: Intermittent   Constant*
Present locations:

Quality:
Relief Measures:
Endocrine
WNL
Fatigue    Lethargic   Generalized weakness
Low endurancePolydipsiaDiaphoresis
DMI DMII
Blood sugar:dl/l
FastingNon-fasting
HypothyroidismHyperthyroidism
Other:*
Immunologic
WNL
Autoimmune disorder
Immunosuppressed (from medication)
Malaise
Rejection syndrome
Cyclic episodic fever
HIV-positive
Hx of MRSA*
Functional
WNL
Activities of daily living:
Independent
Dependent
Needs assistance (select all that apply):
Bathing
Grooming
Dressing
Other:*
Reproductive
Male:
WNL per patient
Benign prostate hyperplasia (BPH)

Female: WNL per patient
Menopausal symptomsPost-menopausal
BRCA/PALB geneNAITFertility issues
Pregnant: Due date*
Labs
None
Lab draw: Via: PIV CVC
Lab type: IgAIgMCBCCBC w/diff
CMPESRPTPTT
IgG troughOther*
FedEx tracking # (Do not list pickup #)
Lab Req.#:
Fall risk assessment (circle the numbers of conditions that apply to the patient)

Confused or disoriented (10)Uncooperative to making changes to reduce fall risk (10)History of falls or falls in the past 3 months (10)Age 70 or older (5)Unsteady gait or unable to ambulate; requires help to transfer (5)Uses assistive device(s) (5)Takes: sedatives, antidepressants, tranquillizers, narcotics, antihypertensive meds, cardiac drugs, anxiolytics, hypoglycemic meds, etc. (5)History of seizures in the past 12 months (5)Impaired vision or hearing (2)Use of diuretics, laxatives, or incontinent of urine or stool (2)Actual or potential for bradycardia or postural hypertension; c/o dizziness (2)
Total score
If total score is > 25 notify prescribing physician and document. If > 15, teach falls prevention techniques.
Source of data (check all that apply):
Patient Spouse/family FriendCaregiver Physician
Comments:
Nurse Signature
Time In & Time Out*

Hour Minutes

Until
until
Hour Minutes
Total 0.0
Total time:
Nurse Name
Nurse

Clear
IG INFUSION FLOW SHEET
Brand Name:
Dose:
Lot#:
Exp. Date:

MonthDayYear
Date
IV Access:

In placeInserted-type:PeripheralPortPICCOther
Gauge: Length:
Insertion site:
Site: WNL Red Pain Edema*
Date inserted if in place:

MonthDayYear
Date
No. of attempts:
>3 attempts Clinical Director notified (Name)
Vein status: Good Fair Poor
Equipment: Gravity Curlin Vista Other:
Flushed with: ml of 0.9% NaCl D5W
Pre-hydration: NS D5W Ringers N/A
Volume ml
Premeds:NoneBenadryl PO/IVmg Tylenol mg ASA mg Zofran mg EMLA cream SoluMedrol mg Other Pt. refusedRN administered

	Time	Temp/Rate	BP	Pulse	Resp	Comments (Problems, tolerance during infusion)
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Nurse Signature

Clear
IG INFUSION FLOW SHEET (CONTINUED)

	Time	Temp/Rate	BP	Pulse	Resp	Comments (Problems, tolerance during infusion)
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Infusion completed:
Infusion site without s/sx of inflammation, infiltration Insertion site infiltrated, see comment.
Access flushed with 0.9% NaClml D5W ml Heparin 10 U/ml 100 U/ml) ml Access maintained.Access removed intact; pressure applied if needed, cleansed, covered with band aid, gauze and tape, or coban.
IVIG rate-related reactions include: headache (pre- and post- infusion), flu-like symptoms, fever, chills, nausea, vomiting, flushing, joint aches, blood pressure changes
and chest tightness. Patient may also exhibit discomfort at IV insertion site. If any of these symptoms occur, stop the infusion for 30 minutes, then resume at half
rate. Always titrate up to desired maximum rate, taking vital signs every 15 minutes x 1 hour, then every 30 minutes for second hour, then every hour till completion.
SoluMedrol infusion patients should be encouraged to hydrate with a flavored beverage during the infusion to mask the metallic after-taste of the drug. Repeat
patient temperature with final vital signs.
Comments/patient goals/progress toward goals:
DC Plan:
No plan to DC, needs ongoing therapy;
DC on.* when treatment is complete.
Nurse Signature

Clear
MEDICATION PROFILE
Patient information
Height:*
Diabetic:

YesNo
Visit Frequency (Ex: Daily x1 every month):

	Start date	Description	Dose	Route	Frequency	Stop date	Initial date
IVIG/SCIG/Other specialty medication:
Pre-medication:
.
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Pre-hydration:
Infusion flushes:
.

Ana-kit medications

	Start date	Dose	Route	Frequency	Exp. date
Diphenhydramine
Epinephrine pen/Adrenaline
Normal saline 0.9%, 500ml

Other medications

	Start date	Description(include prescriptions, OTC, vitamins, herbals)	Dose	Route	Frequency	Stop date	Initial date
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Nurse signature:

Clear
MEDICATION PROFILE (CONTINUED)

Other medications

	Start date	Description (include prescriptions, OTC, vitamins, herbals)	Dose	Route	Frequency	Stop date	Initial date
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Nurse signature:

Clear
NurseID
Location
Should be Empty:

IOC RECERT

COMPREHENSIVE NURSING ASSESSMENT

Immuno/Biologic/Blood Component Therapy

Patient information

Diagnosis

Environmental Safety

Psychosocial

Baseline Vital Signs

Neurological/mental status

Cardiovascular

Skin

Respiratory

Eyes

Ears

Nose

Mouth/Throat

Nutrition

COMPREHENSIVE NURSING ASSESSMENT (CONTINUED)

G.I.

G.U.

Musculoskeletal

Pain

Endocrine

Immunologic

Functional

Reproductive

Labs

Nurse Signature

IG INFUSION FLOW SHEET

IG INFUSION FLOW SHEET (CONTINUED)

MEDICATION PROFILE

Patient information

MEDICATION PROFILE (CONTINUED)