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OP R-EPOCH	

Types:      ONCOLOGY TREATMENT
Synonyms:  DOXORUBICIN, VINCRISTIN, ETOPOSIDE, CADD, RITUXIMAB, METHOTREXATE, CYTARABINE, INTRATHECAL, R EPOCH

Take Home Medication	Repeat 1 time	Cycle length: 7 days	Day 1	Perform every 1 day x1		Take-Home Medications Prior to Treatment
  	predniSONE (DELTASONE) 50 mg tablet	Dose: 100 mg	Route: oral	daily	Dispense: 10 tablet	Refills: 5	Start: S	End: S+5		Instructions:	Take prior to treatment.					
Cycle 1	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION 34	Interval: --	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains OR losses of greater than or equal to 10%.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: --	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
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Labs
  	ABSOLUTE NEUTROPHIL COUNT	Interval: --	Occurrences: --			Labs
  	HEPATITIS B SURFACE ANTIGEN	Interval: --	Occurrences: --		  	HEPATITIS B CORE ANTIBODY TOTAL	Interval: --	Occurrences: --		  	HEPATITIS B SURFACE ANTIBODY	Interval: --	Occurrences: --			Outpatient Electrolyte Replacement Protocol
  	TREATMENT CONDITIONS 39	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Potassium level LESS than 3.5 mEq/L; 
3. Recent pre-infusion labs.   

Dosing is based on lab value.
o Serum potassium less than 3.0mEq/L, give 40mEq KCL IV or PO and contact MD/NP. 
o Serum potassium 3.0 to 3.2mEq/L, give 40mEq KCL IV or PO. 
o Serum potassium 3.3 to 3.4mEq/L, give 20mEq KCL IV or PO. 
o Serum potassium 3.5 mEq/L or greater, do not give potassium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
		  	TREATMENT CONDITIONS 40 	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Magnesium level LESS than 1.6 mg/dL; 
3. Recent pre-infusion labs. 

Dosing is based on lab value. 
o Serum Magnesium less than 1.0 mg/dL, give 2 gram magnesium sulfate IV and contact MD/NP. 
o Serum Magnesium 1.0 to 1.2 mg/dL, give 2 gram magnesium sulfate IV. 
o Serum Magnesium 1.3 to 1.5 mg/dL, give 1 gram magnesium sulfate IV. 
o Serum Magnesium 1.6 mg/dL or greater, do not give magnesium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000.
			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.			Hydration
  	sodium chloride 0.9 % infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 100 mL/hr for 1 dose	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemotherapy			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Day 2	Perform every 1 day x1		Provider Ordering Guidelines
  	ONC PROVIDER COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	If IT chemotherapy is to be administered by IR (interventional radiology) then please KEEP "Lumbar Puncture by Radiology".

If IT chemotherapy will be administered in clinic via Ommaya reservoir then you do NOT need a Lumbar Puncture order. Please REMOVE "Lumbar Puncture by Radiology".
			Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area IF Intrathecal Chemotherapy is administered by IR.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area IF Intrathecal Chemotherapy is administered by IR.
			Intrathecal Injections
  	methotrexate Preservative Free in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: --	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	6 mL	Yes	Yes				Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Days 3,4	Perform every 1 day x2		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Day 5	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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.			Hydration
  	sodium chloride 0.9 % infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 100 mL/hr for 1 dose	Start: S					Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	cyclophosphamide (CYTOXAN) 750 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 750 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	750 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				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.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: --	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: --	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)

			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN					  	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: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Assure patient has outpatient prescriptions for antimicrobial prophylaxis after chemo.
			Supportive Care
  	pegfilgrastim (NEULASTA) on-body injection kit 6 mg	Dose: 6 mg	Route: subcutaneous	once for 1 dose				Instructions:	To inject at least 24 hours after chemotherapy complete.			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					
Cycle 2	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION 34	Interval: --	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains OR losses of greater than or equal to 10%.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: --	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
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Labs
  	ABSOLUTE NEUTROPHIL COUNT	Interval: --	Occurrences: --			Outpatient Electrolyte Replacement Protocol
  	TREATMENT CONDITIONS 39	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Potassium level LESS than 3.5 mEq/L; 
3. Recent pre-infusion labs.   

Dosing is based on lab value.
o Serum potassium less than 3.0mEq/L, give 40mEq KCL IV or PO and contact MD/NP. 
o Serum potassium 3.0 to 3.2mEq/L, give 40mEq KCL IV or PO. 
o Serum potassium 3.3 to 3.4mEq/L, give 20mEq KCL IV or PO. 
o Serum potassium 3.5 mEq/L or greater, do not give potassium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
		  	TREATMENT CONDITIONS 40 	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Magnesium level LESS than 1.6 mg/dL; 
3. Recent pre-infusion labs. 

Dosing is based on lab value. 
o Serum Magnesium less than 1.0 mg/dL, give 2 gram magnesium sulfate IV and contact MD/NP. 
o Serum Magnesium 1.0 to 1.2 mg/dL, give 2 gram magnesium sulfate IV. 
o Serum Magnesium 1.3 to 1.5 mg/dL, give 1 gram magnesium sulfate IV. 
o Serum Magnesium 1.6 mg/dL or greater, do not give magnesium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000.
			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.			Hydration
  	sodium chloride 0.9 % infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 100 mL/hr for 1 dose	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemotherapy			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Day 2	Perform every 1 day x1		Provider Ordering Guidelines
  	ONC PROVIDER COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	If IT chemotherapy is to be administered by IR (interventional radiology) then please KEEP "Lumbar Puncture by Radiology".

If IT chemotherapy will be administered in clinic via Ommaya reservoir then you do NOT need a Lumbar Puncture order. Please REMOVE "Lumbar Puncture by Radiology".
			Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area IF Intrathecal Chemotherapy is administered by IR.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area IF Intrathecal Chemotherapy is administered by IR.
			Intrathecal Injections
  	cytarabine PF (CYSTOSAR) in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: --	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	6 mL	Yes	Yes				Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Days 3,4	Perform every 1 day x2		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Day 5	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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.			Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	cyclophosphamide (CYTOXAN) 750 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 750 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	750 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				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.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: --	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: --	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)

			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN					  	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: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Assure patient has outpatient prescriptions for antimicrobial prophylaxis after chemo.
			Supportive Care
  	pegfilgrastim (NEULASTA) on-body injection kit 6 mg	Dose: 6 mg	Route: subcutaneous	once for 1 dose				Instructions:	To inject at least 24 hours after chemotherapy complete.			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					
Cycle 3	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION 34	Interval: --	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains OR losses of greater than or equal to 10%.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: --	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
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Labs
  	ABSOLUTE NEUTROPHIL COUNT	Interval: --	Occurrences: --			Outpatient Electrolyte Replacement Protocol
  	TREATMENT CONDITIONS 39	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Potassium level LESS than 3.5 mEq/L; 
3. Recent pre-infusion labs.   

Dosing is based on lab value.
o Serum potassium less than 3.0mEq/L, give 40mEq KCL IV or PO and contact MD/NP. 
o Serum potassium 3.0 to 3.2mEq/L, give 40mEq KCL IV or PO. 
o Serum potassium 3.3 to 3.4mEq/L, give 20mEq KCL IV or PO. 
o Serum potassium 3.5 mEq/L or greater, do not give potassium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
		  	TREATMENT CONDITIONS 40 	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Magnesium level LESS than 1.6 mg/dL; 
3. Recent pre-infusion labs. 

Dosing is based on lab value. 
o Serum Magnesium less than 1.0 mg/dL, give 2 gram magnesium sulfate IV and contact MD/NP. 
o Serum Magnesium 1.0 to 1.2 mg/dL, give 2 gram magnesium sulfate IV. 
o Serum Magnesium 1.3 to 1.5 mg/dL, give 1 gram magnesium sulfate IV. 
o Serum Magnesium 1.6 mg/dL or greater, do not give magnesium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000.
			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.			Hydration
  	sodium chloride 0.9 % infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 100 mL/hr for 1 dose	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemotherapy			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Day 2	Perform every 1 day x1		Provider Ordering Guidelines
  	ONC PROVIDER COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	If IT chemotherapy is to be administered by IR (interventional radiology) then please KEEP "Lumbar Puncture by Radiology".

If IT chemotherapy will be administered in clinic via Ommaya reservoir then you do NOT need a Lumbar Puncture order. Please REMOVE "Lumbar Puncture by Radiology".
			Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area IF Intrathecal Chemotherapy is administered by IR.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area IF Intrathecal Chemotherapy is administered by IR.
			Intrathecal Injections
  	methotrexate Preservative Free in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: --	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	6 mL	Yes	Yes				Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Days 3,4	Perform every 1 day x2		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Day 5	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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.			Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	cyclophosphamide (CYTOXAN) 750 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 750 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	750 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				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.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: --	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: --	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)

			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN					  	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: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Assure patient has outpatient prescriptions for antimicrobial prophylaxis after chemo.
			Supportive Care
  	pegfilgrastim (NEULASTA) on-body injection kit 6 mg	Dose: 6 mg	Route: subcutaneous	once for 1 dose				Instructions:	To inject at least 24 hours after chemotherapy complete.			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					
Cycle 4	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION 34	Interval: --	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains OR losses of greater than or equal to 10%.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: --	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
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Labs
  	ABSOLUTE NEUTROPHIL COUNT	Interval: --	Occurrences: --			Outpatient Electrolyte Replacement Protocol
  	TREATMENT CONDITIONS 39	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Potassium level LESS than 3.5 mEq/L; 
3. Recent pre-infusion labs.   

Dosing is based on lab value.
o Serum potassium less than 3.0mEq/L, give 40mEq KCL IV or PO and contact MD/NP. 
o Serum potassium 3.0 to 3.2mEq/L, give 40mEq KCL IV or PO. 
o Serum potassium 3.3 to 3.4mEq/L, give 20mEq KCL IV or PO. 
o Serum potassium 3.5 mEq/L or greater, do not give potassium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
		  	TREATMENT CONDITIONS 40 	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Magnesium level LESS than 1.6 mg/dL; 
3. Recent pre-infusion labs. 

Dosing is based on lab value. 
o Serum Magnesium less than 1.0 mg/dL, give 2 gram magnesium sulfate IV and contact MD/NP. 
o Serum Magnesium 1.0 to 1.2 mg/dL, give 2 gram magnesium sulfate IV. 
o Serum Magnesium 1.3 to 1.5 mg/dL, give 1 gram magnesium sulfate IV. 
o Serum Magnesium 1.6 mg/dL or greater, do not give magnesium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000.
			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.			Hydration
  	sodium chloride 0.9 % infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 100 mL/hr for 1 dose	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemotherapy			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Day 2	Perform every 1 day x1		Provider Ordering Guidelines
  	ONC PROVIDER COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	If IT chemotherapy is to be administered by IR (interventional radiology) then please KEEP "Lumbar Puncture by Radiology".

If IT chemotherapy will be administered in clinic via Ommaya reservoir then you do NOT need a Lumbar Puncture order. Please REMOVE "Lumbar Puncture by Radiology".
			Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area IF Intrathecal Chemotherapy is administered by IR.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area IF Intrathecal Chemotherapy is administered by IR.
			Intrathecal Injections
  	cytarabine PF (CYSTOSAR) in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: --	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	6 mL	Yes	Yes				Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Days 3,4	Perform every 1 day x2		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Day 5	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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.			Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	cyclophosphamide (CYTOXAN) 750 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 750 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	750 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				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.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: --	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: --	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)

			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN					  	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: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Assure patient has outpatient prescriptions for antimicrobial prophylaxis after chemo.
			Supportive Care
  	pegfilgrastim (NEULASTA) on-body injection kit 6 mg	Dose: 6 mg	Route: subcutaneous	once for 1 dose				Instructions:	To inject at least 24 hours after chemotherapy complete.			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					
Cycle 5	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION 34	Interval: --	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains OR losses of greater than or equal to 10%.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: --	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
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Labs
  	ABSOLUTE NEUTROPHIL COUNT	Interval: --	Occurrences: --			Outpatient Electrolyte Replacement Protocol
  	TREATMENT CONDITIONS 39	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Potassium level LESS than 3.5 mEq/L; 
3. Recent pre-infusion labs.   

Dosing is based on lab value.
o Serum potassium less than 3.0mEq/L, give 40mEq KCL IV or PO and contact MD/NP. 
o Serum potassium 3.0 to 3.2mEq/L, give 40mEq KCL IV or PO. 
o Serum potassium 3.3 to 3.4mEq/L, give 20mEq KCL IV or PO. 
o Serum potassium 3.5 mEq/L or greater, do not give potassium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
		  	TREATMENT CONDITIONS 40 	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Magnesium level LESS than 1.6 mg/dL; 
3. Recent pre-infusion labs. 

Dosing is based on lab value. 
o Serum Magnesium less than 1.0 mg/dL, give 2 gram magnesium sulfate IV and contact MD/NP. 
o Serum Magnesium 1.0 to 1.2 mg/dL, give 2 gram magnesium sulfate IV. 
o Serum Magnesium 1.3 to 1.5 mg/dL, give 1 gram magnesium sulfate IV. 
o Serum Magnesium 1.6 mg/dL or greater, do not give magnesium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000.
			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.			Hydration
  	sodium chloride 0.9 % infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 100 mL/hr for 1 dose	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemotherapy			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Day 2	Perform every 1 day x1		Provider Ordering Guidelines
  	ONC PROVIDER COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	If IT chemotherapy is to be administered by IR (interventional radiology) then please KEEP "Lumbar Puncture by Radiology".

If IT chemotherapy will be administered in clinic via Ommaya reservoir then you do NOT need a Lumbar Puncture order. Please REMOVE "Lumbar Puncture by Radiology".
			Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area IF Intrathecal Chemotherapy is administered by IR.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area IF Intrathecal Chemotherapy is administered by IR.
			Intrathecal Injections
  	methotrexate Preservative Free in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: --	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	6 mL	Yes	Yes				Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Days 3,4	Perform every 1 day x2		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Day 5	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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.			Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	cyclophosphamide (CYTOXAN) 750 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 750 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	750 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				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.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: --	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: --	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)

			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN					  	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: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Assure patient has outpatient prescriptions for antimicrobial prophylaxis after chemo.
			Supportive Care
  	pegfilgrastim (NEULASTA) on-body injection kit 6 mg	Dose: 6 mg	Route: subcutaneous	once for 1 dose				Instructions:	To inject at least 24 hours after chemotherapy complete.			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					
Cycle 6	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION 34	Interval: --	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains OR losses of greater than or equal to 10%.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: --	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
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Labs
  	ABSOLUTE NEUTROPHIL COUNT	Interval: --	Occurrences: --			Outpatient Electrolyte Replacement Protocol
  	TREATMENT CONDITIONS 39	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Potassium level LESS than 3.5 mEq/L; 
3. Recent pre-infusion labs.   

Dosing is based on lab value.
o Serum potassium less than 3.0mEq/L, give 40mEq KCL IV or PO and contact MD/NP. 
o Serum potassium 3.0 to 3.2mEq/L, give 40mEq KCL IV or PO. 
o Serum potassium 3.3 to 3.4mEq/L, give 20mEq KCL IV or PO. 
o Serum potassium 3.5 mEq/L or greater, do not give potassium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
		  	TREATMENT CONDITIONS 40 	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Magnesium level LESS than 1.6 mg/dL; 
3. Recent pre-infusion labs. 

Dosing is based on lab value. 
o Serum Magnesium less than 1.0 mg/dL, give 2 gram magnesium sulfate IV and contact MD/NP. 
o Serum Magnesium 1.0 to 1.2 mg/dL, give 2 gram magnesium sulfate IV. 
o Serum Magnesium 1.3 to 1.5 mg/dL, give 1 gram magnesium sulfate IV. 
o Serum Magnesium 1.6 mg/dL or greater, do not give magnesium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000.
			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.			Hydration
  	sodium chloride 0.9 % infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 100 mL/hr for 1 dose	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemotherapy			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Day 2	Perform every 1 day x1		Provider Ordering Guidelines
  	ONC PROVIDER COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	If IT chemotherapy is to be administered by IR (interventional radiology) then please KEEP "Lumbar Puncture by Radiology".

If IT chemotherapy will be administered in clinic via Ommaya reservoir then you do NOT need a Lumbar Puncture order. Please REMOVE "Lumbar Puncture by Radiology".
			Appointment Requests
  	IR LUMBAR PUNCTURE	Interval: --	Occurrences: --			Labs
  	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area IF Intrathecal Chemotherapy is administered by IR.
		  	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --	Comments:	Specimen to be drawn in Interventional Radiology area IF Intrathecal Chemotherapy is administered by IR.
			Intrathecal Injections
  	cytarabine PF (CYSTOSAR) in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: --	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	6 mL	Yes	Yes				Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Days 3,4	Perform every 1 day x2		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2, etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo infusion - AMBULATORY PUMP	Dose: --	Route: intravenous	once over 22 Hours for 1 dose	Start: S			Instructions:	Nurse to chart as GIVEN on MAR. Infuse via CADD pump. Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Yes	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Yes	Yes	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Yes	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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				Day 5	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Ensure patient has taken oral Prednisone from home with chemotherapy.
			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.			Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	cyclophosphamide (CYTOXAN) 750 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 750 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	750 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				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.		  	sodium chloride 0.9 % infusion 500 mL	Dose: 500 mL	Route: intravenous	continuous	Start: S					Pharmacy Consult
  	PHARMACY CONSULT TO SCREEN FOR RITUXIMAB ADMINISTRATION METHOD	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: 90 Minutes	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: --	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: --	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)

			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN					  	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: --	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 4	Interval: --	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 83	Interval: --	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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Assure patient has outpatient prescriptions for antimicrobial prophylaxis after chemo.
			Supportive Care
  	pegfilgrastim (NEULASTA) on-body injection kit 6 mg	Dose: 6 mg	Route: subcutaneous	once for 1 dose				Instructions:	To inject at least 24 hours after chemotherapy complete.			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