| Patient name __________ Patient ID number __________ . |
| _____ mCi of Na131I was administered orally at _____ am/pm on ___ / ___ / ___ . |
| Patient released from the medical center at __________ am/pm on ___ / ___ / ___ . |
| Patient and Family Learning Needs |
| The patient: |
| □ does not have special learning considerations. |
| □ has special learning considerations which will change the method of instruction (specify if present). |
| Patient and Family Instructions |
| (write additional instructions on the back as needed) |
| Safe and effective use of medications. |
| 1. Resume previous thyroid medications as follows: |
| Diet and nutrition. |
| 1. Do not eat for 2 hours following the administration of Na131I, however you may drink clear liquids (water, coffee, tea, fruit juices, and/or soft drinks). |
| 2. Drink as much fluid as tolerable for 48 hours following administration. |
| 3. Chew gum, or suck on hard or sour candy, frequently for 48 hours to encourage the flow of saliva. |
| 4. Use disposable cups, plates, and other dishes and tableware for ___ days. |
| Suggestions to minimize the radiation dose to other people. |
| 1. Avoid sustained close contact with other people for ___ days, especially infants, children, and pregnant women. Remember that radioactive contamination may spread to others through your perspiration, saliva, urine, and feces. |
| 2. Sleep alone for ___ days. |
| 3. Avoid conception for 6 months. |
| Personal hygiene and grooming. |
| 1. Urinate frequently (every 2 hours if possible) for ___ days. Men need to sit down to urinate during this time. |
| 2. Flush the toilet twice after each use and keep your hands clean for ___ days. |
| 3. Shower daily and use separate towels for ___ days. |
| 4. Wear clothing that can be laundered (not dry cleaned) for ___ days. |
| 5. After ___ days wash your clothing, towels, and bedding separately (put through wash/rinse cycles twice). |
| 6. In the rare chance you should vomit within 2 hours of receiving therapy, use paper towels to soak up the material and flush it down the toilet. Try not to spread the material around, as it will be radioactive. Wash your hands. Inform the nuclear medicine staff as soon as possible at __________ [telephone number]. |
| Special Instructions: |
| If you experience any of the following symptoms, contact your physician: |
| Increased shakiness |
| Rapid heart rate |
| Shortness of breath |
| Increasing pain or swelling in the neck over the next 2–3 weeks |
| Difficulty breathing. |
| Important Telephone Numbers |
| After hours urgent calls can be made to the Medical Center Operator at __________ and ask the operator to connect you to the Emergency Care Unit at ext. ___ . |
| During normal business hours (8:00 am–4:30 pm) call Nuclear Medicine at __________ . |
| If you have an Emergency, call 911. |
| Additional Instructions: |