Rituxan-Infusion-Record

							    This sample template is provided by a member of the Rheumatology Nurses Society (RNS) as a resource for RNS
    members to adapt for use in their practice. RNS does not intend for the document to be used as an RNS endorsed
    product. The intent is to provide an example of what is being used by other rheumatology practices in their patient
    care. This document may not meet each nurse’s state, local, or institutional requirements. Responsibility for making
    any revisions to meet those requirements lies with the person adapting the sample template.



RITUXAN INFUSION RECORD                                                                Cycle _______________Dose #1/Dose #2

Date ______________
Name_________________________________________ Weight_________lbs
Diagnosis code: Rheumatoid Arthritis 714.0
Current DMARD____________________________
Allergies_______________________________________
Last Infusion Tolerate Well: Yes No N/A    Comments_______________________________________________

                                  Physician Signature___________________________________________________

Final IV site: ________________________ Number of attempts____________
Catheter: Autoguard/Intima/Huber Gauge 21/22/24       Length ¾, 1, 1 ½ inch Other:_____________
Flushed with Normal Saline 10ml, pre & post infusion. Other:__________________
Primary IVF Start Time_______________________via gravity

Orders: Rituxan 1000 mg in 500 ml Normal Saline IV
Premedicate 30 minutes prior with:
Decadron 20 mg IV Time:______________Lot#________________________Exp______________
Solumedrol 100mg IV Time : _______________Lot #____________________Exp_____________
Solucortef ________mg IV Time:_______________Lot #___________________Exp_______________
Benadryl 25/50 mg po or IV Time:__________Lot#________________________Exp______________
Tylenol 500/650 mg po       Time:__________Lot#________________________Exp______________
Others: ______________________________________________________________________________



For all allergic reactions, STOP INFUSION. Start Normal saline at 100ml/hr.


Rituxan Lot Number________________________________exp___________________________

Patient Monitoring
Vital signs to be taken initially and then Q30 minutes during infusion.

Time Temp. Pulse      Blood pressure IV site Rate cc/hr        Infusion note                                Initials




IV site “X” = No signs of IV site complications observed

Signature_______________________________________________________________ RAPID 3 or 4_____________