Contact Information
Patient Name:
E-mail Address:
Phone Number:
Fax Number:
Preferred Contact Method:
Phone
E-mail
Fax
Inventory of
Supplies
Claves: Blue
self-sealing valve on the end of your IV line.
Claves on Hand:
Claves Needed:
Dressing Change
Kits: Your nurse will use these kits to clean your
IV site.
Dressing Change Kits on Hand:
Dressing Change Kits Needed:
Alcohol Preps:
Use the alcohol preps to clean the end of your IV line,
as well as the top of the saline & heparin vials.
Alcohol Preps on Hand:
Alcohol Preps Needed:
Syringes: These
are used to draw up your flushes.
Syringes on Hand:
Syringes Needed:
Sodium Chloride:
(Saline Vials) Flush your line with this before and after
you administer your therapy.
Sodium Chloride on Hand:
Sodium Chloride Needed:
Heparin Vials:
Flush your line with this after your therapy is complete
(if the MD ordered).
Heparin Vials on Hand:
Heparin Vials Needed:
Tape: Use
this to secure your IV line as needed.
Tape on Hand:
Tape Needed:
Other Supplies
Needed:
Other on Hand:
Other Needed:
If Applicable
to your Therapy
IV Tubing:
Use this to administer your medication (N/A for IV Push).
IV Tubing on Hand:
IV Tubing Needed:
Filters: Use
this on the end of your TPN tubing or with specific therapies.
Filters on Hand:
Filters Needed:
Sterile Covers:
Use this to cover the end of your tubing to protect it.
Sterile Covers on Hand:
Sterile Covers Needed:
IV Extensions:
This allows your IV line to be longer; your nurse will
change these.
IV Extensions on Hand:
IV Extensions Needed:
Huber Needles:
This is used to access your port as needed.
Huber Needles on Hand:
Huber Needles Needed:
Doses of Therapy:
The medication that you use each day.
Doses of Therapy on Hand:
Doses of Therapy Needed:
TPN or Hydration
Additives: This is what you add to your medication
bag (if MD ordered).
TPN or Hydration Additives
on Hand:
TPN or Hydration Additives
Needed:
Other:
Other on Hand
:
Other Needed
:
Questions and Comments:
