Nexplanon Insertion

Consent

Nexplanon Insertion Consent Form

Ensure Woman is Not Pregnant

How to Be Reasonably Certain a Woman Is Not Pregnant

Equipment List

Nitrile exam gloves (1 pair)

Nexplanon device (1 package)

1% Lidocaine with epinephrine (1 vial)

Chux pads (2)

Alcohol swabs (6)

18 Gauge 1.5 inch needle (1)

27 Gauge 1.5 inch needle (1)

5 ml Syringe (1)

ChloraPrep 3 ml stick (1)

Steri strips (1)

Sterile 2x2 gauze (6)

Coban roll (1)

Procedure Note

NEXPLANON INSERTION

After informed consent was obtained and pregnancy reasonably excluded, a time-out was completed.  The patient's _ arm was then prepped in a sterile fashion with a ChloraPrep swab.  A subdermal wheal was created at the entry point, then approximately 5 cc of 1% lidocaine with epinephrine was infused along the planned insertion path.  The needle of the Nexplanon insertion device was inserted into the skin.  Upon insertion the needle was brought horizontal and using a tenting - advance motion the needle was advanced to its entire length.  The applicator button was depressed and Nexplanon rod remained in place after the device was removed.  The rod was palpated in place subdermally by both the physician and the patient.  Minimal bleeding.  The patient tolerated the procedure well.  A Steri-strip and gauze dressing was applied over the insertion site and a pressure dressing was applied over the area.  Post procedure instructions & precautions were given, including: keep compression dressing in place for 24 hours, then keep area clean and covered (with Band-Aid or gauze dressing) until healed, usually 3-5 days.  Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills, the implant comes out or you have concerns about its location, or you have a positive pregnancy test or suspect you might be pregnant.  Patient instructed to use a back-up form of birth control for 7 days past insertion date.  Wallet card given.

Patient informed replacement date is three years from today.