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IP MATRIX	

Types:      ONCOLOGY TREATMENT
Synonyms:  RITUXAN, TRUXIMA, METHOTREXATE, THIOPLEX, FOLINIC ACID

Cycle 1	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Provider Communication
  	ONC PROVIDER COMMUNICATION 64	Interval: Once	Occurrences: --	Comments:	Verify Hep B panel status prior to cycle. Date *** of panel. Result positive/negative/pending/unknown:22867

The required components for the hepatitis B panel includes: Hepatitis B surface antigen (HBsAg), total hepatitis B core antibody (anti-HBc), and hepatitis B antibody (anti-HBs).
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Until discontinued	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains/losses of greater than or equal to 10%.
			Provider Communication
  	ONC PROVIDER COMMUNICATION 14	Interval: Until discontinued	Occurrences: --	Comments:	No salicylates, NSAIDS or sulfa drugs concurrent or a week before treatment starts. No proton pump inhibitors. Restrict carbonated beverages.
			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: --		  	PH, URINALYSIS	Interval: Once	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 0.1.
			Labs
  	HEPATITIS B SURFACE ANTIGEN	Interval: Once	Occurrences: --		  	HEPATITIS B CORE ANTIBODY TOTAL	Interval: Once	Occurrences: --		  	HEPATITIS B SURFACE ANTIBODY	Interval: Once	Occurrences: --			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) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.			Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	Interval: Until discontinued	Occurrences: --			Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	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	Interval: Until discontinued	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	Start: S			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				Nursing Orders
  	ONC NURSING COMMUNICATION 2	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 0.1.

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.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	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				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 0.1 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Medications	150 mEq	Always	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	850 mL	Yes	Yes	WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION	QS Base	 	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	 	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	 	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	 	No	Yes	SODIUM CHLORIDE 0.2 % INTRAVENOUS SOLUTION (SIMPLE)	QS Base	 	No	Yes				Supportive Care
  	prednisoLONE acetate (PRED FORTE) 1 % ophthalmic suspension 2 drop	Dose: 2 drop	Route: Both Eyes	every 4 hours while awake	Start: S				  	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 Preservative Free 500 mg/m2 in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 500 mg/m2	Route: intravenous	once over 15 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	500 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes			  	methotrexate Preservative Free 3,000 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 3,000 mg/m2	Route: intravenous	once over 3 Hours for 1 dose			Offset: 45 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	3,000 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				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 Cetirizine 10 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), Cetirizine 10 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				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once 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: Timed	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 0.1.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	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 0.1.

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.
			Line Care
  	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			  	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 5	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 2,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 2,000 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.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	2,000 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			  	leucovorin 15 mg/m2 in sodium chloride 0.9% 100 mL IVPB	Dose: 15 mg/m2	Route: intravenous	every 6 hours over 30 Minutes	Start: S			Instructions:	Begin 24 hours AFTER START of methotrexate infusion, and then Give every 6 hours.

Continue every 6 hours until Methotrexate levels are LESS than 0.1 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION	Medications	15 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes					Day 3	Perform every 1 day x1		Labs
  	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		  	PH, URINALYSIS	Interval: Timed	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 0.1.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	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 0.1.

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.
			Line Care
  	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				Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 2,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 2,000 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.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	2,000 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					Day 4	Perform every 1 day x1		Line Care
  	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				Chemotherapy
  	thiotepa (PF) 30 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 30 mg/m2	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Infuse with 0.22 micron filter. Patients should shower twice daily while receiving thiotepa and for 48 hours after completion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	THIOTEPA 15 MG SOLUTION FOR INJECTION	Medications	30 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 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) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.			Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	Interval: Until discontinued	Occurrences: --			Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	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	Interval: Until discontinued	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	Start: S			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						
Cycle 2	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Until discontinued	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains/losses of greater than or equal to 10%.
			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: --		  	PH, URINALYSIS	Interval: Once	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 0.1.
			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) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.			Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	Interval: Until discontinued	Occurrences: --			Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	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	Interval: Until discontinued	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	Start: S			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				Nursing Orders
  	ONC NURSING COMMUNICATION 2	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 0.1.

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.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	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				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 0.1 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Medications	150 mEq	Always	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	850 mL	Yes	Yes	WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION	QS Base	 	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	 	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	 	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	 	No	Yes	SODIUM CHLORIDE 0.2 % INTRAVENOUS SOLUTION (SIMPLE)	QS Base	 	No	Yes				Supportive Care
  	prednisoLONE acetate (PRED FORTE) 1 % ophthalmic suspension 2 drop	Dose: 2 drop	Route: Both Eyes	every 4 hours while awake	Start: S				  	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 Preservative Free 500 mg/m2 in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 500 mg/m2	Route: intravenous	once over 15 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	500 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes			  	methotrexate Preservative Free 3,000 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 3,000 mg/m2	Route: intravenous	once over 3 Hours for 1 dose			Offset: 45 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	3,000 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				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 Cetirizine 10 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), Cetirizine 10 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				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once 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: Timed	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 0.1.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	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 0.1.

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.
			Line Care
  	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			  	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 5	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 2,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 2,000 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.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	2,000 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			  	leucovorin 15 mg/m2 in sodium chloride 0.9% 100 mL IVPB	Dose: 15 mg/m2	Route: intravenous	every 6 hours over 30 Minutes	Start: S			Instructions:	Begin 24 hours AFTER START of methotrexate infusion, and then Give every 6 hours.

Continue every 6 hours until Methotrexate levels are LESS than 0.1 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION	Medications	15 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes					Day 3	Perform every 1 day x1		Labs
  	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		  	PH, URINALYSIS	Interval: Timed	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 0.1.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	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 0.1.

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.
			Line Care
  	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				Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 2,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 2,000 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.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	2,000 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					Day 4	Perform every 1 day x1		Line Care
  	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				Chemotherapy
  	thiotepa (PF) 30 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 30 mg/m2	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Infuse with 0.22 micron filter. Patients should shower twice daily while receiving thiotepa and for 48 hours after completion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	THIOTEPA 15 MG SOLUTION FOR INJECTION	Medications	30 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 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) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.			Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	Interval: Until discontinued	Occurrences: --			Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	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	Interval: Until discontinued	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	Start: S			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						
Cycle 3	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Until discontinued	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains/losses of greater than or equal to 10%.
			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: --		  	PH, URINALYSIS	Interval: Once	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 0.1.
			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) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.			Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	Interval: Until discontinued	Occurrences: --			Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	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	Interval: Until discontinued	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	Start: S			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				Nursing Orders
  	ONC NURSING COMMUNICATION 2	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 0.1.

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.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	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				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 0.1 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Medications	150 mEq	Always	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	850 mL	Yes	Yes	WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION	QS Base	 	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	 	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	 	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	 	No	Yes	SODIUM CHLORIDE 0.2 % INTRAVENOUS SOLUTION (SIMPLE)	QS Base	 	No	Yes				Supportive Care
  	prednisoLONE acetate (PRED FORTE) 1 % ophthalmic suspension 2 drop	Dose: 2 drop	Route: Both Eyes	every 4 hours while awake	Start: S				  	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 Preservative Free 500 mg/m2 in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 500 mg/m2	Route: intravenous	once over 15 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	500 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes			  	methotrexate Preservative Free 3,000 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 3,000 mg/m2	Route: intravenous	once over 3 Hours for 1 dose			Offset: 45 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	3,000 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				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 Cetirizine 10 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), Cetirizine 10 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				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once 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: Timed	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 0.1.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	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 0.1.

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.
			Line Care
  	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			  	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 5	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 2,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 2,000 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.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	2,000 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			  	leucovorin 15 mg/m2 in sodium chloride 0.9% 100 mL IVPB	Dose: 15 mg/m2	Route: intravenous	every 6 hours over 30 Minutes	Start: S			Instructions:	Begin 24 hours AFTER START of methotrexate infusion, and then Give every 6 hours.

Continue every 6 hours until Methotrexate levels are LESS than 0.1 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION	Medications	15 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes					Day 3	Perform every 1 day x1		Labs
  	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		  	PH, URINALYSIS	Interval: Timed	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 0.1.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	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 0.1.

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.
			Line Care
  	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				Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 2,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 2,000 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.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	2,000 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					Day 4	Perform every 1 day x1		Line Care
  	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				Chemotherapy
  	thiotepa (PF) 30 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 30 mg/m2	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Infuse with 0.22 micron filter. Patients should shower twice daily while receiving thiotepa and for 48 hours after completion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	THIOTEPA 15 MG SOLUTION FOR INJECTION	Medications	30 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 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) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.			Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	Interval: Until discontinued	Occurrences: --			Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	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	Interval: Until discontinued	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	Start: S			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						
Cycle 4	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Until discontinued	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains/losses of greater than or equal to 10%.
			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: --		  	PH, URINALYSIS	Interval: Once	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 0.1.
			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) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.			Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	Interval: Until discontinued	Occurrences: --			Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	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	Interval: Until discontinued	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	Start: S			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				Nursing Orders
  	ONC NURSING COMMUNICATION 2	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 0.1.

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.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	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				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 0.1 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Medications	150 mEq	Always	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	850 mL	Yes	Yes	WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION	QS Base	 	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	 	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	 	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	 	No	Yes	SODIUM CHLORIDE 0.2 % INTRAVENOUS SOLUTION (SIMPLE)	QS Base	 	No	Yes				Supportive Care
  	prednisoLONE acetate (PRED FORTE) 1 % ophthalmic suspension 2 drop	Dose: 2 drop	Route: Both Eyes	every 4 hours while awake	Start: S				  	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 Preservative Free 500 mg/m2 in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 500 mg/m2	Route: intravenous	once over 15 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	500 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes			  	methotrexate Preservative Free 3,000 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 3,000 mg/m2	Route: intravenous	once over 3 Hours for 1 dose			Offset: 45 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	3,000 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				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 Cetirizine 10 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), Cetirizine 10 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				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once 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: Timed	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 0.1.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	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 0.1.

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.
			Line Care
  	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			  	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 5	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 2,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 2,000 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.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	2,000 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			  	leucovorin 15 mg/m2 in sodium chloride 0.9% 100 mL IVPB	Dose: 15 mg/m2	Route: intravenous	every 6 hours over 30 Minutes	Start: S			Instructions:	Begin 24 hours AFTER START of methotrexate infusion, and then Give every 6 hours.

Continue every 6 hours until Methotrexate levels are LESS than 0.1 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION	Medications	15 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes					Day 3	Perform every 1 day x1		Labs
  	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		  	PH, URINALYSIS	Interval: Timed	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 0.1.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	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 0.1.

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.
			Line Care
  	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				Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: Until discontinued	Occurrences: --	Comments:	Have patient sign name as cerebellar assessment prior to each dose of Cytarabine.
			Chemotherapy
  	cytarabine PF (CYSTOSAR) 2,000 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 2,000 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.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	2,000 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					Day 4	Perform every 1 day x1		Line Care
  	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				Chemotherapy
  	thiotepa (PF) 30 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 30 mg/m2	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Infuse with 0.22 micron filter. Patients should shower twice daily while receiving thiotepa and for 48 hours after completion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	THIOTEPA 15 MG SOLUTION FOR INJECTION	Medications	30 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 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) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Give 30 minutes before rituximab infusion.			Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	Interval: Until discontinued	Occurrences: --			Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	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	Interval: Until discontinued	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	Start: S			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