HEMODIALYSIS THERAPY PLAN		version 3/1/2024		

Appointment Requests 	

	
	Interval	Defer Until	Duration	
	☐	Referral to IV Infusion Room	Once	S	1 treatment	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine		
	☐	Nursing communication	Every visit	S	Until discont'd	
		Please continue to schedule subsequent infusion appointments manually as appropriate.		

Labs 	

	
	Interval	Defer Until	Duration	
	☐	Hepatitis B surface antigen	On the 1st Mon of every 1 month	S	Until discont'd	
		Once, Blood, Clinic Collect		
	☐	Hepatitis B surface antibody	On the 1st Mon of every 1 month	S	Until discont'd	
		Once, Blood, Clinic Collect		
	☐	Iron level	On the 1st Mon of every 1 month	S	Until discont'd	
		Once, Blood, Clinic Collect		
	☐	Comprehensive metabolic panel	On the 1st Mon of every 1 month	S	Until discont'd	
		Once, Blood, Clinic Collect		
	☐	Renal function panel	On the 1st Mon of every 1 month	S	Until discont'd	
		Once, Blood, Clinic Collect		
	☐	CBC hemogram	On the 1st Mon of every 1 month	S	Until discont'd	
		Once, Blood, Clinic Collect		
	☐	Ferritin level	Quarterly	S	Until discont'd	
		Once, Blood, Clinic Collect		
	☐	Parathyroid hormone	Quarterly	S	Until discont'd	
		Once, Blood, Clinic Collect		

Dialysis Treatment Orders 	

	
	Interval	Defer Until	Duration	
	☐	Nasal cannula oxygen	Every visit	S	Until discont'd	
		Once, Clinic Performed		
	☐	Hemodialysis outpatient	Every visit	S	Until discont'd	
		Once
	K+: 2 mg
	Ca++: 2.5 mg
	Bicarb: 35 meq
	Na+: 138 meq
	Na+ Modeling: Yes (please comment Sodium Amount)
	Dialyzer: F160
	Dialysate Temperature (C): 37
	Blood Flow Rate-As tolerated to a maximum of: 450 mL/min
	Dialysate Flow Rate: 600 mL/min
	Duration of Treatment: 4 Hours
	Tubing: 8 mm
	Access Site: AVF
	Clinic Performed		

Dialysis Medications 	

	
	Interval	Defer Until	Duration	
	☐	iron sucrose (VENOFER) injection (RESTRICTED) 100 mg	Every visit	S	Until discont'd	
		100 mg, intravenous, once in dialysis		
	☐	doxercalciferoL (HECTOROL) injection 4 mcg	Every visit	S	Until discont'd	
		4 mcg, intravenous, once in dialysis		
	☐	darbepoetin alfa-polysorbate (ARANESP) injection 2.25 mcg/kg	Every visit	S	Until discont'd	
		2.25 mcg/kg, intravenous, once, Starting when released		

Dialysis Medications PRN 	

	
	Interval	Defer Until	Duration	
	☐	acetaminophen (TYLENOL) tablet 325 mg	PRN	S	Until discont'd	
		325 mg, oral, every 4 hours PRN, Pain, Until Discontinued
	Maximum dose of acetaminophen is 4000 mg from all sources in 24 hours.
	Maximum of 4 grams of acetaminophen per day from all sources. (Cirrhosis patients maximum: 2 grams per day from all sources).		
	☐	nitroglycerin (NITROSTAT) SL tablet 0.4 mg	PRN	S	Until discont'd	
		0.4 mg, sublingual, once
	Do not crush, split, or chew.		
	☐	HEParin (porcine) injection 5,000 Units	PRN	S	Until discont'd	
		5,000 Units, intravenous, once		
	☐	alteplase (CATHFLO) for Quinton and Hemodialysis Catheters 2 mg	PRN	S	Until discont'd	
		2 mg, Other, once
	2 mg dose of Cathflo is for Quinton and Hemodialysis Catheter Clearance.