Protocol Index	

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IP R-HYPERCVAD A AND B (ALTERNATING)	

Types:      ONCOLOGY TREATMENT
Synonyms:  HYERCVAD, LYMPH, CYCLO, MESNA, DOXO, VINCR, CVAD, DECA, ADRIA, PART A , CYTOX

Pre-Treatment Cycle	Repeat 1 time	Cycle length: 1 day	Day 1	Perform every 1 day x1		Pre-Medications
  	dexamethasone (DECADRON) 4 MG tablet	Dose: 40 mg	Route: oral	daily with breakfast	Dispense: 60 tablet	Refills: 3	Start: S	End: S+4		Instructions:	As directed by Doctor.  Days 1-4 and 11-14.					
HyperCVAD Part 1A	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Labs
  	HEPATITIS B SURFACE ANTIGEN	Interval: Once	Occurrences: --		  	HEPATITIS B CORE ANTIBODY TOTAL	Interval: Once	Occurrences: --		  	HEPATITIS B SURFACE ANTIBODY	Interval: Once	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Verify Ejection Fraction prior to Cycle 1.  Ejection Fraction: ***% on *** (date).

If patient has not had a recent MUGA or ECHO, order one via order entry. A baseline cardiac evaluation with a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiac toxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses.

			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1000; Platelets LESS than 100,000.
			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Hydration
  	sodium chloride 0.9 % infusion	Dose: 100 mL/hr	Route: intravenous	continuous	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Rituximab Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral		Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RAPID RITUXIMAB INFUSION	Interval: --	Occurrences: --			Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Once	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Once	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (T greater than 38.5 degrees C), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and / or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% INITIAL INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion at rate of 50 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), then increase infusion rate by 50 mg/hour every 30 minutes, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% INITIAL INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion at rate of 50 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), then increase infusion rate by 50 mg/hour every 30 minutes, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% INITIAL INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion at rate of 50 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), then increase infusion rate by 50 mg/hour every 30 minutes, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% INITIAL INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion at rate of 50 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), then increase infusion rate by 50 mg/hour every 30 minutes, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: --	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: --	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: --	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: --	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☑	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.			Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Nursing Orders
  	ONC NURSING COMMUNICATION 59	Interval: Until discontinued	Occurrences: --	Comments:	First mesna bag needs to start at the same time as cyclophosphamide initiation.
			Chemotherapy
☑	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				☑	cyclophosphamide (CYTOXAN) 300 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☑	mesna (MESNEX) 600 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes				Supportive Care
  	allopurinol (ZYLOPRIM) tablet 300 mg	Dose: 300 mg	Route: oral	2 times daily	Start: S			Instructions:	Dosing: reduce dose to 100 mg if Acute Renal Failure.			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only – itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 – MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms – shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	fexofenadine (ALLEGRA) tablet 180 mg	Dose: 180 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Day 2	Perform every 1 day x1		Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
☑	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				☑	cyclophosphamide (CYTOXAN) 300 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☑	mesna (MESNEX) 600 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes				Intrathecal Injections
  	methotrexate PF 12 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 12 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	12 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	5.52 mL	Yes	Yes					Day 3	Perform every 1 day x1		Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
☑	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				☑	cyclophosphamide (CYTOXAN) 300 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☑	mesna (MESNEX) 600 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes					Day 4	Perform every 1 day x1		Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
  	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				  	DOXOrubicin (ADRIAmycin) 50 mg/m2 in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Protect from light; VESICANT	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			  	vinCRIStine (ONCOVIN) 1.4 mg/m2 in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 1.4 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 45 Minutes	Instructions:	Protect from light, VESICANT.  Maximum Dose = 2 mg.	Rule-Based Template: RULE ONCBCN VINCRISTINE 1.4 MG/M2	  Conditions:	  Modifications:	  BSA < 1.43 m2	  Set dose to 1.4 mg/m2	  BSA >= 1.43 m2	  Set dose to 2 mg	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	1.4 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes					Outpatient Day 11	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --		☐	LDH	Interval: --	Occurrences: --		☐	URIC ACID LEVEL	Interval: --	Occurrences: --			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Remind patient to take Dexamethasone on Days 1 through 4, and Days 11 through 14.  Some doses may be given in hospital / clinic.
			Rituximab Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral		Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RAPID RITUXIMAB INFUSION	Interval: --	Occurrences: --			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Until discontinued	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Until discontinued	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (temperature greater than 38.5 degrees Celsius), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and/or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only – itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 – MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms – shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	fexofenadine (ALLEGRA) tablet 180 mg	Dose: 180 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Chemotherapy
  	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				  	vinCRIStine (ONCOVIN) 1.4 mg/m2 in sodium chloride 0.9 % 50 mL chemo IVPB	Dose: 1.4 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Instructions:	Protect from light, VESICANT.  Max dose = 2 mg.	Rule-Based Template: RULE ONCBCN VINCRISTINE 1.4 MG/M2	  Conditions:	  Modifications:	  BSA < 1.43 m2	  Set dose to 1.4 mg/m2	  BSA >= 1.43 m2	  Set dose to 2 mg	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	1.4 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes				Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	CSF CELL COUNT WITH DIFFERENTIAL	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	PROTEIN, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	GLUCOSE LEVEL, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
			Intrathecal Injections
  	cytarabine PF (CYSTOSAR) 100 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 100 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care.  Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	100 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.			Discharge Nursing Orders
  	alteplase (CATHFLO) for NON Quinton and NON Hemodialysis Catheters 2 mg	Dose: 2 mg	Route: intra-catheter	once PRN	Start: S			Instructions:	HOLD and notify provider if Platelets LESS than 50.  Instill dose into occluded catheter. Do not force solution into
catheter. After a 30-minute dwell time, assess catheter function by attempting
to aspirate blood. If catheter is functional, aspirate 4 to 5 mL of blood in
patients greater than or equal to 10 kg to remove Cathflo Activase and
residual clots. Gently irrigate the catheter with NS. If catheter remains
nonfunctional, let Cathflo Activase dwell for another 90 minutes (total dwell
time: 120 minutes) and reassess function. If catheter function is not restored,
a second dose may be instilled					
HyperCVAD Part 1B	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Labs
  	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every 8 hours until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1000; Platelets LESS than 100,000.
			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
  	sodium bicarbonate 150 mEq in dextrose 5% 1,000 mL infusion	Dose: 150 mL/hr	Route: intravenous	continuous	Start: S			Instructions:	Hydrate patient for 4 hours PRIOR to checking urine pH. 

Run until methotrexate level is LESS than 0.05 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	850 mL	Yes	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	150 mEq	Yes	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Provider Communication
  	ONC PROVIDER COMMUNICATION 13	Interval: Once	Occurrences: --	Comments:	Provider to confirm dose for patients over 60 years of age for Cytarabine.
			Supportive Care
  	prednisoLONE acetate (PRED FORTE) 1 % ophthalmic suspension 2 drop	Dose: 2 drop	Route: Both Eyes	every 4 hours while awake	Start: S					Supportive Care
  	allopurinol (ZYLOPRIM) tablet 300 mg	Dose: 300 mg	Route: oral	2 times daily	Start: S			Instructions:	Dosing: reduce dose to 100 mg if Acute Renal Failure.			Chemotherapy
  	methotrexate PF 200 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 200 mg/m2	Route: intravenous	once over 120 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	200 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	methotrexate PF 800 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 800 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	800 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes				Rituximab Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral		Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RAPID RITUXIMAB INFUSION	Interval: --	Occurrences: --			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Until discontinued	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Until discontinued	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (temperature greater than 38.5 degrees Celsius), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and/or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only – itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 – MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms – shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	fexofenadine (ALLEGRA) tablet 180 mg	Dose: 180 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Day 2	Perform every 1 day x1		Labs
☑	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		☑	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting Methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every day until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☑	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.			Nursing Orders
  	ONC NURSING COMMUNICATION 68	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 3,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 3,000 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Instructions:	Cytarabine dosing:
if serum creatinine GREATER than 1.5 = Cytarabine 1 gm.
If age GREATER than 60 years old = Cytarabine 1.5 gm.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	3,000 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes				Chemotherapy
  	leucovorin IV 50 mg	Dose: 50 mg	Route: intravenous	every 6 hours over 30 Minutes				Instructions:	Begin 12 hours AFTER COMPLETION of methotrexate infusion, and then Give every 6 hours.

Continue every 6 hours until Methotrexate levels are LESS than 0.05 micromol/L.			Intrathecal Injections
  	methotrexate PF 12 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 12 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	12 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	5.52 mL	Yes	Yes					Day 3	Perform every 1 day x1		Labs
☑	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		☑	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting Methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every day until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Nursing Orders
  	ONC NURSING COMMUNICATION 68	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 3,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 3,000 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Instructions:	Cytarabine dosing:
if serum creatinine GREATER than 1.5 = Cytarabine 1 gm.
If age GREATER than 60 years old = Cytarabine 1.5 gm.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	3,000 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes					Outpatient Day 11	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --		☐	LDH	Interval: --	Occurrences: --		☐	URIC ACID LEVEL	Interval: --	Occurrences: --			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Rituximab Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral		Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RAPID RITUXIMAB INFUSION	Interval: --	Occurrences: --			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Until discontinued	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Until discontinued	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (temperature greater than 38.5 degrees Celsius), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and/or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only – itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 – MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms – shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	fexofenadine (ALLEGRA) tablet 180 mg	Dose: 180 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	CSF CELL COUNT WITH DIFFERENTIAL	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	PROTEIN, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	GLUCOSE LEVEL, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
			Intrathecal Injections
  	cytarabine PF (CYSTOSAR) 100 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 100 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care.  Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	100 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1 mL	Yes	Yes						
HyperCVAD Part 2A	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Verify Ejection Fraction prior to Cycle 1.  Ejection Fraction: ***% on *** (date).

If patient has not had a recent MUGA or ECHO, order one via order entry. A baseline cardiac evaluation with a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiac toxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses.

			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1000; Platelets LESS than 100,000.
			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Rituximab Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral		Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RAPID RITUXIMAB INFUSION	Interval: --	Occurrences: --			Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Once	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Once	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (T greater than 38.5 degrees C), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and / or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☑	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.			Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Nursing Orders
  	ONC NURSING COMMUNICATION 59	Interval: Until discontinued	Occurrences: --	Comments:	First mesna bag needs to start at the same time as cyclophosphamide initiation.
			Chemotherapy
☑	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				☑	cyclophosphamide (CYTOXAN) 300 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☑	mesna (MESNEX) 600 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes				Supportive Care
  	allopurinol (ZYLOPRIM) tablet 300 mg	Dose: 300 mg	Route: oral	2 times daily	Start: S			Instructions:	Dosing: reduce dose to 100 mg if Acute Renal Failure.			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only – itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 – MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms – shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	fexofenadine (ALLEGRA) tablet 180 mg	Dose: 180 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Day 2	Perform every 1 day x1		Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
☑	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				☑	cyclophosphamide (CYTOXAN) 300 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☑	mesna (MESNEX) 600 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes				Intrathecal Injections
  	methotrexate PF 12 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 12 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	12 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	5.52 mL	Yes	Yes					Day 3	Perform every 1 day x1		Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
☑	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				☑	cyclophosphamide (CYTOXAN) 300 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☑	mesna (MESNEX) 600 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes					Day 4	Perform every 1 day x1		Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
  	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				  	DOXOrubicin (ADRIAmycin) 50 mg/m2 in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Protect from light; VESICANT	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			  	vinCRIStine (ONCOVIN) 1.4 mg/m2 in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 1.4 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 45 Minutes	Instructions:	Protect from light, VESICANT.  Maximum Dose = 2 mg.	Rule-Based Template: RULE ONCBCN VINCRISTINE 1.4 MG/M2	  Conditions:	  Modifications:	  BSA < 1.43 m2	  Set dose to 1.4 mg/m2	  BSA >= 1.43 m2	  Set dose to 2 mg	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	1.4 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes					Outpatient Day 11	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --		☐	LDH	Interval: --	Occurrences: --		☐	URIC ACID LEVEL	Interval: --	Occurrences: --			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Remind patient to take Dexamethasone on Days 1 through 4, and Days 11 through 14.  Some doses may be given in hospital / clinic.
			Rituximab Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral		Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RAPID RITUXIMAB INFUSION	Interval: --	Occurrences: --			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Until discontinued	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Until discontinued	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (temperature greater than 38.5 degrees Celsius), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and/or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only – itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 – MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms – shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	fexofenadine (ALLEGRA) tablet 180 mg	Dose: 180 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Chemotherapy
  	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				  	vinCRIStine (ONCOVIN) 1.4 mg/m2 in sodium chloride 0.9 % 50 mL chemo IVPB	Dose: 1.4 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Instructions:	Protect from light, VESICANT.  Max dose = 2 mg.	Rule-Based Template: RULE ONCBCN VINCRISTINE 1.4 MG/M2	  Conditions:	  Modifications:	  BSA < 1.43 m2	  Set dose to 1.4 mg/m2	  BSA >= 1.43 m2	  Set dose to 2 mg	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	1.4 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes				Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	CSF CELL COUNT WITH DIFFERENTIAL	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	PROTEIN, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	GLUCOSE LEVEL, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
			Intrathecal Injections
  	cytarabine PF (CYSTOSAR) 100 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 100 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care.  Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	100 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.			Discharge Nursing Orders
  	alteplase (CATHFLO) for NON Quinton and NON Hemodialysis Catheters 2 mg	Dose: 2 mg	Route: intra-catheter	once PRN	Start: S			Instructions:	HOLD and notify provider if Platelets LESS than 50.  Instill dose into occluded catheter. Do not force solution into
catheter. After a 30-minute dwell time, assess catheter function by attempting
to aspirate blood. If catheter is functional, aspirate 4 to 5 mL of blood in
patients greater than or equal to 10 kg to remove Cathflo Activase and
residual clots. Gently irrigate the catheter with NS. If catheter remains
nonfunctional, let Cathflo Activase dwell for another 90 minutes (total dwell
time: 120 minutes) and reassess function. If catheter function is not restored,
a second dose may be instilled					
HyperCVAD Part 2B	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Labs
  	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every 8 hours until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1000; Platelets LESS than 100,000.
			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
  	sodium bicarbonate 150 mEq in dextrose 5% 1,000 mL infusion	Dose: 150 mL/hr	Route: intravenous	continuous	Start: S			Instructions:	Hydrate patient for 4 hours PRIOR to checking urine pH. 

Run until methotrexate level is LESS than 0.05 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	850 mL	Yes	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	150 mEq	Yes	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Provider Communication
  	ONC PROVIDER COMMUNICATION 13	Interval: Once	Occurrences: --	Comments:	Provider to confirm dose for patients over 60 years of age for Cytarabine.
			Supportive Care
  	prednisoLONE acetate (PRED FORTE) 1 % ophthalmic suspension 2 drop	Dose: 2 drop	Route: Both Eyes	every 4 hours while awake	Start: S					Supportive Care
  	allopurinol (ZYLOPRIM) tablet 300 mg	Dose: 300 mg	Route: oral	2 times daily	Start: S			Instructions:	Dosing: reduce dose to 100 mg if Acute Renal Failure.			Chemotherapy
  	methotrexate PF 200 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 200 mg/m2	Route: intravenous	once over 120 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	200 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	methotrexate PF 800 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 800 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	800 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes				Rituximab Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral		Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RAPID RITUXIMAB INFUSION	Interval: --	Occurrences: --			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Until discontinued	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Until discontinued	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (temperature greater than 38.5 degrees Celsius), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and/or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only – itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 – MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms – shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	fexofenadine (ALLEGRA) tablet 180 mg	Dose: 180 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Day 2	Perform every 1 day x1		Labs
☑	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		☑	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting Methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every day until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☑	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.			Nursing Orders
  	ONC NURSING COMMUNICATION 68	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 3,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 3,000 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Instructions:	Cytarabine dosing:
if serum creatinine GREATER than 1.5 = Cytarabine 1 gm.
If age GREATER than 60 years old = Cytarabine 1.5 gm.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	3,000 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes				Chemotherapy
  	leucovorin IV 50 mg	Dose: 50 mg	Route: intravenous	every 6 hours over 30 Minutes				Instructions:	Begin 12 hours AFTER COMPLETION of methotrexate infusion, and then Give every 6 hours.

Continue every 6 hours until Methotrexate levels are LESS than 0.05 micromol/L.			Intrathecal Injections
  	methotrexate PF 12 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 12 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	12 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	5.52 mL	Yes	Yes					Day 3	Perform every 1 day x1		Labs
☑	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		☑	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting Methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every day until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Nursing Orders
  	ONC NURSING COMMUNICATION 68	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 3,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 3,000 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Instructions:	Cytarabine dosing:
if serum creatinine GREATER than 1.5 = Cytarabine 1 gm.
If age GREATER than 60 years old = Cytarabine 1.5 gm.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	3,000 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes					Outpatient Day 11	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --		☐	LDH	Interval: --	Occurrences: --		☐	URIC ACID LEVEL	Interval: --	Occurrences: --			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Rituximab Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral		Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RAPID RITUXIMAB INFUSION	Interval: --	Occurrences: --			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Until discontinued	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Until discontinued	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (temperature greater than 38.5 degrees Celsius), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and/or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only – itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 – MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms – shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	fexofenadine (ALLEGRA) tablet 180 mg	Dose: 180 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	CSF CELL COUNT WITH DIFFERENTIAL	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	PROTEIN, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	GLUCOSE LEVEL, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
			Intrathecal Injections
  	cytarabine PF (CYSTOSAR) 100 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 100 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care.  Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	100 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1 mL	Yes	Yes						
HyperCVAD Part 3A	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Verify Ejection Fraction prior to Cycle 1.  Ejection Fraction: ***% on *** (date).

If patient has not had a recent MUGA or ECHO, order one via order entry. A baseline cardiac evaluation with a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiac toxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses.

			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1000; Platelets LESS than 100,000.
			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Rituximab Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral		Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RAPID RITUXIMAB INFUSION	Interval: --	Occurrences: --			Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Once	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Once	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (T greater than 38.5 degrees C), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and / or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☑	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.			Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Nursing Orders
  	ONC NURSING COMMUNICATION 59	Interval: Until discontinued	Occurrences: --	Comments:	First mesna bag needs to start at the same time as cyclophosphamide initiation.
			Chemotherapy
☑	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				☑	cyclophosphamide (CYTOXAN) 300 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☑	mesna (MESNEX) 600 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes				Supportive Care
  	allopurinol (ZYLOPRIM) tablet 300 mg	Dose: 300 mg	Route: oral	2 times daily	Start: S			Instructions:	Dosing: reduce dose to 100 mg if Acute Renal Failure.			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only – itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 – MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms – shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	fexofenadine (ALLEGRA) tablet 180 mg	Dose: 180 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Day 2	Perform every 1 day x1		Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
☑	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				☑	cyclophosphamide (CYTOXAN) 300 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☑	mesna (MESNEX) 600 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes				Intrathecal Injections
  	methotrexate PF 12 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 12 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	12 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	5.52 mL	Yes	Yes					Day 3	Perform every 1 day x1		Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
☑	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				☑	cyclophosphamide (CYTOXAN) 300 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☑	mesna (MESNEX) 600 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes					Day 4	Perform every 1 day x1		Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
  	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				  	DOXOrubicin (ADRIAmycin) 50 mg/m2 in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Protect from light; VESICANT	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			  	vinCRIStine (ONCOVIN) 1.4 mg/m2 in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 1.4 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 45 Minutes	Instructions:	Protect from light, VESICANT.  Maximum Dose = 2 mg.	Rule-Based Template: RULE ONCBCN VINCRISTINE 1.4 MG/M2	  Conditions:	  Modifications:	  BSA < 1.43 m2	  Set dose to 1.4 mg/m2	  BSA >= 1.43 m2	  Set dose to 2 mg	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	1.4 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes					Outpatient Day 11	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --		☐	LDH	Interval: --	Occurrences: --		☐	URIC ACID LEVEL	Interval: --	Occurrences: --			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Remind patient to take Dexamethasone on Days 1 through 4, and Days 11 through 14.  Some doses may be given in hospital / clinic.
			Chemotherapy
  	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				  	vinCRIStine (ONCOVIN) 1.4 mg/m2 in sodium chloride 0.9 % 50 mL chemo IVPB	Dose: 1.4 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Instructions:	Protect from light, VESICANT.  Max dose = 2 mg.	Rule-Based Template: RULE ONCBCN VINCRISTINE 1.4 MG/M2	  Conditions:	  Modifications:	  BSA < 1.43 m2	  Set dose to 1.4 mg/m2	  BSA >= 1.43 m2	  Set dose to 2 mg	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	1.4 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes				Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	CSF CELL COUNT WITH DIFFERENTIAL	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	PROTEIN, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	GLUCOSE LEVEL, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
			Intrathecal Injections
  	cytarabine PF (CYSTOSAR) 100 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 100 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care.  Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	100 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.			Discharge Nursing Orders
  	alteplase (CATHFLO) for NON Quinton and NON Hemodialysis Catheters 2 mg	Dose: 2 mg	Route: intra-catheter	once PRN	Start: S			Instructions:	HOLD and notify provider if Platelets LESS than 50.  Instill dose into occluded catheter. Do not force solution into
catheter. After a 30-minute dwell time, assess catheter function by attempting
to aspirate blood. If catheter is functional, aspirate 4 to 5 mL of blood in
patients greater than or equal to 10 kg to remove Cathflo Activase and
residual clots. Gently irrigate the catheter with NS. If catheter remains
nonfunctional, let Cathflo Activase dwell for another 90 minutes (total dwell
time: 120 minutes) and reassess function. If catheter function is not restored,
a second dose may be instilled					
HyperCVAD Part 3B	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Labs
  	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every 8 hours until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1000; Platelets LESS than 100,000.
			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
  	sodium bicarbonate 150 mEq in dextrose 5% 1,000 mL infusion	Dose: 150 mL/hr	Route: intravenous	continuous	Start: S			Instructions:	Hydrate patient for 4 hours PRIOR to checking urine pH. 

Run until methotrexate level is LESS than 0.05 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	850 mL	Yes	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	150 mEq	Yes	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Provider Communication
  	ONC PROVIDER COMMUNICATION 13	Interval: Once	Occurrences: --	Comments:	Provider to confirm dose for patients over 60 years of age for Cytarabine.
			Supportive Care
  	prednisoLONE acetate (PRED FORTE) 1 % ophthalmic suspension 2 drop	Dose: 2 drop	Route: Both Eyes	every 4 hours while awake	Start: S					Supportive Care
  	allopurinol (ZYLOPRIM) tablet 300 mg	Dose: 300 mg	Route: oral	2 times daily	Start: S			Instructions:	Dosing: reduce dose to 100 mg if Acute Renal Failure.			Chemotherapy
  	methotrexate PF 200 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 200 mg/m2	Route: intravenous	once over 120 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	200 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	methotrexate PF 800 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 800 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	800 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes				Rituximab Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral		Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RAPID RITUXIMAB INFUSION	Interval: --	Occurrences: --			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Until discontinued	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Until discontinued	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (temperature greater than 38.5 degrees Celsius), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and/or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only – itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 – MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms – shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	fexofenadine (ALLEGRA) tablet 180 mg	Dose: 180 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Day 2	Perform every 1 day x1		Labs
☑	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		☑	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting Methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every day until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☑	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.			Nursing Orders
  	ONC NURSING COMMUNICATION 68	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 3,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 3,000 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Instructions:	Cytarabine dosing:
if serum creatinine GREATER than 1.5 = Cytarabine 1 gm.
If age GREATER than 60 years old = Cytarabine 1.5 gm.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	3,000 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes				Chemotherapy
  	leucovorin IV 50 mg	Dose: 50 mg	Route: intravenous	every 6 hours over 30 Minutes				Instructions:	Begin 12 hours AFTER COMPLETION of methotrexate infusion, and then Give every 6 hours.

Continue every 6 hours until Methotrexate levels are LESS than 0.05 micromol/L.			Intrathecal Injections
  	methotrexate PF 12 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 12 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	12 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	5.52 mL	Yes	Yes					Day 3	Perform every 1 day x1		Labs
☑	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		☑	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting Methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every day until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Nursing Orders
  	ONC NURSING COMMUNICATION 68	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 3,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 3,000 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Instructions:	Cytarabine dosing:
if serum creatinine GREATER than 1.5 = Cytarabine 1 gm.
If age GREATER than 60 years old = Cytarabine 1.5 gm.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	3,000 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes					Outpatient Day 11	Perform every 1 day x1		Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	CSF CELL COUNT WITH DIFFERENTIAL	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	PROTEIN, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	GLUCOSE LEVEL, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
			Intrathecal Injections
  	cytarabine PF (CYSTOSAR) 100 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 100 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care.  Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	100 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1 mL	Yes	Yes						
HyperCVAD Part 4A	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Verify Ejection Fraction prior to Cycle 1.  Ejection Fraction: ***% on *** (date).

If patient has not had a recent MUGA or ECHO, order one via order entry. A baseline cardiac evaluation with a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiac toxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses.

			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1000; Platelets LESS than 100,000.
			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Rituximab Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral		Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RAPID RITUXIMAB INFUSION	Interval: --	Occurrences: --			Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Once	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Once	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (T greater than 38.5 degrees C), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and / or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☑	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.			Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Nursing Orders
  	ONC NURSING COMMUNICATION 59	Interval: Until discontinued	Occurrences: --	Comments:	First mesna bag needs to start at the same time as cyclophosphamide initiation.
			Chemotherapy
☑	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				☑	cyclophosphamide (CYTOXAN) 300 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☑	mesna (MESNEX) 600 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes				Supportive Care
  	allopurinol (ZYLOPRIM) tablet 300 mg	Dose: 300 mg	Route: oral	2 times daily	Start: S			Instructions:	Dosing: reduce dose to 100 mg if Acute Renal Failure.			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only – itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 – MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms – shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	fexofenadine (ALLEGRA) tablet 180 mg	Dose: 180 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Day 2	Perform every 1 day x1		Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
☑	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				☑	cyclophosphamide (CYTOXAN) 300 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☑	mesna (MESNEX) 600 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes				Intrathecal Injections
  	methotrexate PF 12 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 12 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	12 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	5.52 mL	Yes	Yes					Day 3	Perform every 1 day x1		Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
☑	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				☑	cyclophosphamide (CYTOXAN) 300 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☑	mesna (MESNEX) 600 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes					Day 4	Perform every 1 day x1		Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				☐	ondansetron (ZOFRAN), dexamethasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
  	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				  	DOXOrubicin (ADRIAmycin) 50 mg/m2 in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Protect from light; VESICANT	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			  	vinCRIStine (ONCOVIN) 1.4 mg/m2 in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 1.4 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 45 Minutes	Instructions:	Protect from light, VESICANT.  Maximum Dose = 2 mg.	Rule-Based Template: RULE ONCBCN VINCRISTINE 1.4 MG/M2	  Conditions:	  Modifications:	  BSA < 1.43 m2	  Set dose to 1.4 mg/m2	  BSA >= 1.43 m2	  Set dose to 2 mg	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	1.4 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes					Outpatient Day 11	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --		☐	LDH	Interval: --	Occurrences: --		☐	URIC ACID LEVEL	Interval: --	Occurrences: --			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Remind patient to take Dexamethasone on Days 1 through 4, and Days 11 through 14.  Some doses may be given in hospital / clinic.
			Chemotherapy
  	dexamethasone (DECADRON) tablet 40 mg	Dose: 40 mg	Route: oral	once for 1 dose	Start: S				  	vinCRIStine (ONCOVIN) 1.4 mg/m2 in sodium chloride 0.9 % 50 mL chemo IVPB	Dose: 1.4 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Instructions:	Protect from light, VESICANT.  Max dose = 2 mg.	Rule-Based Template: RULE ONCBCN VINCRISTINE 1.4 MG/M2	  Conditions:	  Modifications:	  BSA < 1.43 m2	  Set dose to 1.4 mg/m2	  BSA >= 1.43 m2	  Set dose to 2 mg	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	1.4 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes				Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	CSF CELL COUNT WITH DIFFERENTIAL	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	PROTEIN, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	GLUCOSE LEVEL, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
			Intrathecal Injections
  	cytarabine PF (CYSTOSAR) 100 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 100 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care.  Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	100 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.			Discharge Nursing Orders
  	alteplase (CATHFLO) for NON Quinton and NON Hemodialysis Catheters 2 mg	Dose: 2 mg	Route: intra-catheter	once PRN	Start: S			Instructions:	HOLD and notify provider if Platelets LESS than 50.  Instill dose into occluded catheter. Do not force solution into
catheter. After a 30-minute dwell time, assess catheter function by attempting
to aspirate blood. If catheter is functional, aspirate 4 to 5 mL of blood in
patients greater than or equal to 10 kg to remove Cathflo Activase and
residual clots. Gently irrigate the catheter with NS. If catheter remains
nonfunctional, let Cathflo Activase dwell for another 90 minutes (total dwell
time: 120 minutes) and reassess function. If catheter function is not restored,
a second dose may be instilled					
HyperCVAD Part 4B	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Labs
  	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every 8 hours until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1000; Platelets LESS than 100,000.
			Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Hydration
  	sodium bicarbonate 150 mEq in dextrose 5% 1,000 mL infusion	Dose: 150 mL/hr	Route: intravenous	continuous	Start: S			Instructions:	Hydrate patient for 4 hours PRIOR to checking urine pH. 

Run until methotrexate level is LESS than 0.05 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	850 mL	Yes	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	150 mEq	Yes	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Provider Communication
  	ONC PROVIDER COMMUNICATION 13	Interval: Once	Occurrences: --	Comments:	Provider to confirm dose for patients over 60 years of age for Cytarabine.
			Supportive Care
  	prednisoLONE acetate (PRED FORTE) 1 % ophthalmic suspension 2 drop	Dose: 2 drop	Route: Both Eyes	every 4 hours while awake	Start: S					Supportive Care
  	allopurinol (ZYLOPRIM) tablet 300 mg	Dose: 300 mg	Route: oral	2 times daily	Start: S			Instructions:	Dosing: reduce dose to 100 mg if Acute Renal Failure.			Chemotherapy
  	methotrexate PF 200 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 200 mg/m2	Route: intravenous	once over 120 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	200 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	methotrexate PF 800 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 800 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	800 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes				Rituximab Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral		Start: S			Instructions:	Give 30 minutes before rituximab infusion.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RAPID RITUXIMAB INFUSION	Interval: --	Occurrences: --			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 3 Hours	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 3 Hours	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Until discontinued	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Until discontinued	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (temperature greater than 38.5 degrees Celsius), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and/or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only – itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 – MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms – shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Fexofenadine 180 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	fexofenadine (ALLEGRA) tablet 180 mg	Dose: 180 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Day 2	Perform every 1 day x1		Labs
☑	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		☑	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting Methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every day until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		☑	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.			Nursing Orders
  	ONC NURSING COMMUNICATION 68	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 3,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 3,000 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Instructions:	Cytarabine dosing:
if serum creatinine GREATER than 1.5 = Cytarabine 1 gm.
If age GREATER than 60 years old = Cytarabine 1.5 gm.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	3,000 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes				Chemotherapy
  	leucovorin IV 50 mg	Dose: 50 mg	Route: intravenous	every 6 hours over 30 Minutes				Instructions:	Begin 12 hours AFTER COMPLETION of methotrexate infusion, and then Give every 6 hours.

Continue every 6 hours until Methotrexate levels are LESS than 0.05 micromol/L.			Intrathecal Injections
  	methotrexate PF 12 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 12 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	12 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	5.52 mL	Yes	Yes					Day 3	Perform every 1 day x1		Labs
☑	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		☑	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting Methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every day until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Nursing Orders
  	ONC NURSING COMMUNICATION 68	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 3,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 3,000 mg/m2	Route: intravenous	every 12 hours over 120 Minutes for 2 doses			Offset: 30 Minutes	Instructions:	Cytarabine dosing:
if serum creatinine GREATER than 1.5 = Cytarabine 1 gm.
If age GREATER than 60 years old = Cytarabine 1.5 gm.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	3,000 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes					Outpatient Day 11	Perform every 1 day x1		Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	CSF CELL COUNT WITH DIFFERENTIAL	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	PROTEIN, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	GLUCOSE LEVEL, CSF	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area.
			Intrathecal Injections
  	cytarabine PF (CYSTOSAR) 100 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 100 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care.  Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	100 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1 mL	Yes	Yes