PARENTERAL CONSUMERS ONLY

4. Nutrition Related Information
Infusion Schedule:
I have been on the attached formula since _____/_____. (Attach a label from your bag.)
Infusion Volume: __________ Rate: _________ Over______ # hours
I infuse _______ #days/week
Time: ____ Overnight _____ Daytime _____ Around the Clock (check one)

Additives: (i.e. MVI, Iron, Vitamin K and Medications...additional list may be attached)
The following substances are added to my HPN:

Additives	Amount	Frequency

I infuse lipids: _____ Yes _____ No (check one)
If yes, as a: ____ 3-in-1 Solution ___ Separate Solution (check one)
I infuse extra hydration (Attach label from bag): _____ Yes _____ No (check one)
If yes: Volume: ________ Rate: ________
I use gloves and mask when hooking up (Recommended for pts with direct connect lines or ports):
___ Yes ____ No (check one)

Other Pertinent Information

Recent Lab Values: (See attached Lab Results)
Daily Input/Output: Usual Weight _________ (may be a range)

Input Volume	Output Volume
Oral:	Urine:
IV:	Ostomy:
Tube:	Other:
Total:	Total:

5. Access Information/Protocols

Central Venous Catheter:
Type: (check one) ____ Externalized Catheter ____ Port _____ PICC
Brand Name: _____________________ Size: _______________
Date Inserted: ____/_____/_____
Inserted at Institution: _______________________
By: ____ Surgeon ___ Vascular Radiologist ____ Nurse ____ Other __________________
Phone #: (_________) _________ — _____________

If multilumen:
_____ lumen is for TPN
_____ lumen is for ______________ (blood draws, pain meds, etc.)

Flushing Protocol:
Solution: (i.e. saline, heparin)____________________________________
Amount: ____________ Frequency: ________________________

I use gloves and mask when flushing (Recommended for pts with direct connect lines or ports):
____ Yes ____ No (check one)

Dressing Change Protocol:
Frequency: ___________________________________
Dressing Type: ________________________________
Skin Prep Solution: ____________________________
Catheter/Securement Method: (check one)
_____ Subcutaneous Cuff ____ Tape _____ Sutures ____ None

I use gloves and mask when changing my dressing (Recommended for all pts):
____ Yes ____ No (check one)

Cap Change Protocol:
Type: ________________________________________
Frequency: ____________________________________

I use gloves and mask when changing my cap (Recommended for all pts):
____ Yes ____ No (check one)

6. Pump & Supplies

1. Brand: _____________________ Mfg: ______________________
Used for: _______ PN _____ EN _____ Pain Meds (check one)
Pump Tubing Brand & Reorder #: ______________________________________
Attachment Tubing (for EN button) Brand & Reorder #_______________________

2. Brand: _____________________ Mfg: ______________________
Used for: _______ PN _____ EN _____ Pain Meds (check one)
Pump Tubing Brand & Reorder #: ______________________________________
Attachment Tubing (for EN button) Brand & Reorder #_______________________

7. Ostomy (Output) Supplies & Protocol

Type of Ostomy: (check one) ______ jejunostomy ______ileostomy _____colostomy
Date Created: ____/____/____
Institution/Surgeon: ___________________________
Phone #: (_________) _________ — _____________

I use the following for my appliance:
Type of Pouch: ____________________
Type of Wafer: ____________________
Type of Skin Prep: _________________
I change my dressing/pouch every ____________ days.

I use gloves when changing my ostomy dressing:
____ Yes ____ No (check one)