Nexplanon Replacement Consent Form
Nitrile exam gloves (1 pair)
Sterile gloves (1 pair)
1% lidocaine with epinephrine (1 vial)
Mosquito curved ridged hemostat (1)
11 Blade disposable scalpel (1)
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 3mL stick (1)
Steri strips (1)
Sterile 2x2 gauze (6)
Coban roll (1)
The Nexplanon rod in place was palpated in the patient's _ arm in the appropriate position. After informed consent was obtained, and time-out completed, the patient's left arm was prepped in a sterile fashion with a ChloraPrep swab. Approximately 5 cc of 1% lidocaine with epinephrine was infused along the planned incision site, and below and along the palpated rod. An incision was made, the device brought to the level of the incision. The rod was removed intact and verified by patient and physician. Patient tolerated procedure well. Minimal bleeding throughout procedure. Steri-Strips were placed over incision, and covered by sterile gauze and pressure dressing. Minimal (<1 ml) blood loss during procedure. Post procedure instructions & precautions were given, including: keep top compression dressing in place for 24 hours, then dressing can be removed but allow Steri-strips to remain in place for 3-5 days. Keep the area clean and dry until fully healed. Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills. Patient informed that effective immediately she must use another form of birth control if pregnancy is not desired.
The needle of the Nexplanon insertion device was inserted into the skin through the newly created incision site. 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. Wallet card given.
Patient informed replacement date: _.