Immediately document the time of administration, dosage, and route (slow IV push). Note the patient’s response within 15 minutes, including any adverse effects, such as headache, dizziness, or drowsiness. Record the patient’s heart rate and blood pressure before and after administration.
Monitoring Vital Signs and Adverse Effects
Continue monitoring vital signs regularly, according to facility protocol, paying close attention to any changes. Thoroughly document all observations, including the time and specific details of any adverse reactions. If the patient experiences significant changes, report these findings to the physician immediately. Report any suspected medication errors without delay.
Record Keeping and Reporting
Maintain accurate records of all Zofran administrations and related observations in the patient’s medical chart. This should include the date, time, dose, route, and any adverse effects experienced. Use clear and concise language, avoiding ambiguous terminology.
| 14:00 | BP: 120/80, HR: 72 | Zofran 4mg slow IV push administered. |
| 14:15 | BP: 118/78, HR: 70 | Patient reports mild drowsiness. |
| 14:30 | BP: 122/82, HR: 75 | Drowsiness subsided. |
Physician Notification
Inform the physician promptly of any unexpected or significant adverse reactions, regardless of severity. This includes, but is not limited to, severe bradycardia, hypotension, or prolonged QT interval. Ensure you provide accurate information about the event timeline, patient response, and any interventions taken.
