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Depo Provera Injections (102.077)

Depo Provera Injections (102.077) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Medications, Drug-Specific

102.077


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UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL GUIDELINE

TITLE: DEPO-PROVERA INJECTION

Effective Date: August, 2004 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education

Reviewed March, 2005 Feb., 2008 May, 2009 September, 2012 September, 2013
February 2014 September 2015

PURPOSE: To provide guidelines for the administration, documentation and patient instruction of Depo-Provera 150 mg/ml
injections at University of Wisconsin Medical Foundation (UWMF) and Department of Family Medicine (DFM) clinic.

DEFINITION: Depo-Provera (medroxyprogesterone acetate), is a contraceptive injection for women that contains the hormone
progestin.

BACKGROUND INFORMATION:
Depo-Provera is effective as a contraceptive immediately when given in the first 5 days of the menstrual period. Depo-Provera is
given as an intramuscular (IM) injection once every three months and is over 99% effective in preventing pregnancy.
Depo-Provera does not protect against HIV or other sexually transmitted diseases. Depo-Provera should not be used by pregnant
women, or women with the following histories: vaginal bleeding without a known cause, breast cancer, stroke, or liver disease.

POLICY STATEMENT:
1. The clinical staff will utilize the following guidelines to administer Depo Provera to UWMF female patients.
2. If any questions from staff or the patient arise as they initiate the process with a patient, the Depo-Provera injection &
process MUST be double checked by 2 clinic staff members; with 1 member being an RN or higher in licensure.
3. ONLY the date(s) under Immunization/Injections section on Snap Shot page; will be used to verify future injections dates.
4. Clinical Staff Education will be responsible to ensure clinics are using the most up-to-date perpetual calendar.
5. This guideline is written for Depo Provera 150mg. If another strength or dose is prescribed, this guideline should not be
followed.
6. Clinical staff administering Depo-Provera will complete an annual computer based education.

SUPPLIES:
Provider’s order, Patient’s medical record
Ordered medication: Depo-Provera 150 mg/ml
Correct needle length and gauge for IM administration
UWHealth: Health Facts for You: Depo-Provera #5501
Depo-Provera perpetual calendar (copyright date 1999)

GENERAL GUIDELINE:

1. Check provider’s order and clarify any inconsistencies.
Note: Order should be reviewed and reordered annually by provider.

2. Wash hands and gather supplies.

3. Review medication order, adhering to the five rights of drug administration.
ξ Right – patient, drug, dose, time, route, including expiration date of the medication

4. Introduce yourself to the patient and identify patient using patient’s full name and date of birth.


INITIAL DEPO-PROVERA INJECTION

1. Obtain patient’s weight and blood pressure and document findings in the electronic chart.

2. Confirm that patient is within the first 5 days of her menstrual cycle.
ξ No pregnancy test is necessary during these 5 days.

3. If the patient is not within the first 5 days of her menstrual cycle, obtain a urine pregnancy test (UPT).


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ξ If results of UPT are negative, proceed with steps below and instruct patient to use a back-up form of birth control
for one week/7 days.
ξ If results of UPT are positive, notify provider.

NOTE: If the patient has a history of irregular periods, is an unreliable historian, has had unprotected intercourse in the last 14
days, or cannot determine the date of last unprotected sexual intercourse, consult provider about how to proceed.

4. Patient teaching should be completed by using the Health Facts for You handout (#5501).
ξ Patient will be provided a copy of the HFFY to use for future reference.
ξ Patient will be provided a copy of the Depo-Provera Perpetual calendar for future reference (for 150mg dosing).

5. Check medical record for last appointment with ordering provider.
ξ If patient needs future appointments for physical, etc, assist her with appointments at the end of the injection. Try to
schedule injections at same time as future appointments; however DO NOT withhold injection to match a future
appointment.

6. Administer injection as directed by manufacturer.

7. Follow-up steps for future Depo-Provera injection.
ξ Provide patient with the AVS, to include the next injection date range.
(Next injection date range for (150mg/ml) can be calculated using the 1999 Depo-Provera manufacturer’s perpetual
calendar.)
ξ If patient is not able to make an appointment for the next injection, include the clinic phone number on the AVS.
ξ If patient is able to make the next appointment, direct patient to receptionist to make the appointment.

8. See Injection Documentation.

SUBSEQUENT DEPO-PROVERA INJECTIONS

1. Obtain patient’s weight and blood pressure and document findings in the electronic chart.

2. Check patient’s medical record regarding previous injection date.
ξ Use date found under the Immunization/Injection section on Snap Shot page to verify that patient is on-time for
injection.
ξ The date range for the 150 mg/ml injection is between 11and 13 weeks from the previous injection date. (Use
manufacturer’s perpetual calendar)

NOTE: If previous injection was given at another facility, retrieve or request injection history from that
facility. Patient may need to complete a ‘release of information’ form if given outside Care Everywhere within Healthlink.

3. Follow steps 4-6 above.


IF PATIENT IS LATE FOR DEPO-PROVERA INJECTION

1. If last injection was greater than 13 weeks:
ξ Determine if patient has had unprotected sexual intercourse within the past 14 days.
 If yes, instruct patient to abstain from intercourse or use another reliable form of birth control for 14 days and return
to clinic at that time for a urine pregnancy test.
 If no, obtain a urine pregnancy test.
o If urine pregnancy test is positive, consult with provider.
o If urine pregnancy test is negative, proceed with medication administration and instruct patient to use an
additional form of birth control for 14 days.
ξ Reinforce to patient the need to keep to the Depo-Provera injection schedule.




FIRST DEPO-PROVERA INJECTION POST CHILDBIRTH


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1. The first injection post childbirth can depend on whether the mother is breast-feeding, the presence of risk factors for hormonal
contraception, or at the discretion of the provider.
ξ If breast-feeding, the mother should wait 6 weeks after the birth to begin the Depo-Provera injections unless otherwise
directed by the provider. Instruct the mother (and partner) to use other forms of birth control during these 6 weeks.
Delaying administration allows for establishment of breastfeeding and adequate milk supply.
ξ If not breast-feeding, the mother may begin the Depo-Provera injections within 5 days after the birth of the child or at the
discretion of the provider. The patient may have received the injection prior to discharge from the hospital.
ξ See Injection Documentation.

INJECTION DOCUMENTATION

1. Visit Encounter: use “Contraception” as the Chief Complaint
ξ Use the “Injection – Contraception” SmartSet
2. Progress Notes: utilizing the following smart phrases as applicable: .npdepoproverainitial or .npdepoprovera
ξ This phrase is available in the Contraception Smart Set and this documentation will be placed in the Progress Note
area.
3. Imm/Injections section: include the following:
ξ Name of medication, dose, route, site of injection, and time given
ξ Manufacture, Lot #, NDC#, Expiration date

RECEPTION PROCESS FOR SCHEDULING (If patient calls into the clinic)

1. First time Depo-Provera injection – start phone message and route call to RN/triage or directly transfer call to RN/Triage.
2. Subsequent Depo-Provera injection – schedule appt, route Re: Patient message to RN/LPN/MA to verify that appointment date is
acceptable, RN/LPN/MA to contact patient if appointment date needs to be changed.
3. Late Depo-Provera injection– start phone message and route call to RN/triage or directly transfer call to RN/Triage.

WRITTEN BY: Ronnie Peterson, R.N., M.S., Manager of Clinical Support
REVISED BY: LaVay Morrison, RN, BSN, Clinical Staff Educator
Diane Mikelsons, RN, MN, Clinical Staff Educator
REVIEWED BY: Lori Hauschild, RN MHA, Clinic Operations Director – Primary Care
Shabvon Johnson, RN MBA, Clinic Operations Director - Specialty
Ronnie Peterson, MSN, Manager of Clinical Support
Mary Ryan, RN, BSN, Clinical Staff Educator
Sarah Bradley MD, UWMF OB/GYN – General Department
REFERENCES:
1. Contraceptive Technology, Hatcher, 19th Ed. Ardent Media Inc.
2. Drug Dosages & Solutions, 3rd Ed. Norville, Appleton & Lange
3. Nursing 2011 Drug Handbook, Springhouse Pub.
AUTHORIZED BY: Richard Welnick, MD, Medical Director, UWMF Ambulatory Clinic Operations
Sandra A. Kamnetz M.D., Vice Chair, Department of Family Medicine


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Medical Director, UWMF Date

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Vice Chair, Department of Family Medicine Date