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OP SIPULEUCEL-T (PROVENGE) EVERY 14 DAYS	

Types:      ONCOLOGY TREATMENT
Synonyms:  AUTOLOGOUS, CD54+, MALE, PROSTATE, STAGE 4

Cycle 1	Repeat 1 time	Cycle length: 14 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION 64	Interval: --	Occurrences: --	Comments:	Verify Hep B panel status prior to cycle. Date *** of panel. Result positive/negative/pending/unknown:22867

The required components for the hepatitis B panel includes: Hepatitis B surface antigen (HBsAg), total hepatitis B core antibody (anti-HBc), and hepatitis B antibody (anti-HBs).
			Labs
  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --	Comments:	PRIOR TO Immunotherapy.
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --	Comments:	PRIOR TO Immunotherapy.
		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --	Comments:	PRIOR TO Immunotherapy.
			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.
			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer at least 30 minutes prior to Sipuleucel-T.		  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer at least 30 minutes prior to Sipuleucel-T.		  	famotidine (PEPCID) tablet 20 mg	Dose: 20 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer at least 30 minutes prior to Sipuleucel-T.  NOTE:  Patient to start on day of apheresis and continue throughout treatment.			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	For autologous use only.
		  	ONC NURSING COMMUNICATION 80	Interval: --	Occurrences: --	Comments:	Identity of patient MUST match patient identifiers on the infusion bag AND on the "Final Product Disposition Notification" prior to infusion.
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	DO NOT infuse until confirmation of product release is received from Dendreon Pharmaceuticals.
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Keep sealed infusion bag in the insulated polyurethane container inside the shipping box until ready for administration.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Prior to infusion, inspect bag for signs of leaks-DO NOT administer if leaking or damaged.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	Gently mix to resuspend contents.
		  	ONC NURSING COMMUNICATION 10	Interval: --	Occurrences: --	Comments:	Inspect for clumps or clotting.
		  	ONC NURSING COMMUNICATION 11	Interval: --	Occurrences: --	Comments:	Small clumps should disperse with the gentle mixing (for up to 3 minutes if necessary).
		  	ONC NURSING COMMUNICATION 12	Interval: --	Occurrences: --	Comments:	DO NOT administer if clumps remain.  Contact/Report to Dendreon OnCall.
		  	ONC NURSING COMMUNICATION 14	Interval: --	Occurrences: --	Comments:	Infusion must begin prior to the expiration date and time.
		  	ONC NURSING COMMUNICATION 15	Interval: --	Occurrences: --	Comments:	DO NOT infuse if expired.
			Line Flush
  	lactated ringer's infusion 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	lactated ringer's infusion 250 mL	Dose: 250 mL	Route: intravenous	continuous @ 30 mL/hr				Instructions:	To keep vein open			Chemotherapy
  	sipuleucel-T-lactated ringers (PROVENGE) 50 million cell/250 mL infusion (RESTRICTED) 250 mL	Dose: 250 mL	Route: intravenous	once over 60 Minutes for 1 dose	Start: S	End: S		Instructions:	Do not use PROVENGE until confirmation of product release is received from Dendreon. Do not use a cell filter.

Dendreon will send the Final Product Disposition Notification form containing the patient identifiers, expiration date and time, and the disposition status (approved for infusion or rejected), to the infusion site. Infusion must begin prior to the expiration date and time indicated on the Final Product Disposition Notification form and Product Label. Do not use expired PROVENGE. Keep the sealed, patient-specific PROVENGE infusion bag within the insulated polyurethane container inside the outer cardboard shipping box until the time of administration.

Observe the patient for acute infusion reactions for at least 30 minutes following each infusion. If acute infusion reactions occur, such as chills, fatigue, fever, nausea, and joint ache, interrupt or slow the infusion and administer appropriate medical treatment as needed. If the infusion is interrupted, keep the PROVENGE infusion bag at room temperature. Do not resume infusion if the PROVENGE infusion bag has been at room temperature for more than 3 hours.

Do not administer if the bag leaks during handling, is damaged, or if clumps remain in the bag.			PRN Medications
  	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once PRN	Start: S				  	promethazine (PHENERGAN) 12.5 mg in sodium chloride 0.9% 10 mL injection	Dose: 12.5 mg	Route: intravenous	once PRN	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	PROMETHAZINE 25 MG/ML INJECTION SOLUTION	Medications	12.5 mg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	Base	10 mL	Always	Yes			  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S					PRN Medications
  	alteplase (CATHFLO) for Quinton and Hemodialysis Catheters 2 mg	Dose: 2 mg	Route: intra-catheter	once PRN	Start: S			Instructions:	Instructions:  Notify MD.  Draw labs via peripheral vein access.  Hold and notify MD   if platelet count is less than 50,000. 
2 mg dose of Cathflo is for Quinton and Hemodialysis Catheter Clearance.			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					
Cycles 2,3	Repeat 2 times	Cycle length: 14 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --	Comments:	PRIOR TO Immunotherapy.
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --	Comments:	PRIOR TO Immunotherapy.
		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --	Comments:	PRIOR TO Immunotherapy.
			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.
			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer at least 30 minutes prior to Sipuleucel-T.		  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer at least 30 minutes prior to Sipuleucel-T.		  	famotidine (PEPCID) tablet 20 mg	Dose: 20 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer at least 30 minutes prior to Sipuleucel-T.  NOTE:  Patient to start on day of apheresis and continue throughout treatment.			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	For autologous use only.
		  	ONC NURSING COMMUNICATION 80	Interval: --	Occurrences: --	Comments:	Identity of patient MUST match patient identifiers on the infusion bag AND on the "Final Product Disposition Notification" prior to infusion.
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	DO NOT infuse until confirmation of product release is received from Dendreon Pharmaceuticals.
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Keep sealed infusion bag in the insulated polyurethane container inside the shipping box until ready for administration.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Prior to infusion, inspect bag for signs of leaks-DO NOT administer if leaking or damaged.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	Gently mix to resuspend contents.
		  	ONC NURSING COMMUNICATION 10	Interval: --	Occurrences: --	Comments:	Inspect for clumps or clotting.
		  	ONC NURSING COMMUNICATION 11	Interval: --	Occurrences: --	Comments:	Small clumps should disperse with the gentle mixing (for up to 3 minutes if necessary).
		  	ONC NURSING COMMUNICATION 12	Interval: --	Occurrences: --	Comments:	DO NOT administer if clumps remain.  Contact/Report to Dendreon OnCall.
		  	ONC NURSING COMMUNICATION 14	Interval: --	Occurrences: --	Comments:	Infusion must begin prior to the expiration date and time.
		  	ONC NURSING COMMUNICATION 15	Interval: --	Occurrences: --	Comments:	DO NOT infuse if expired.
			Line Flush
  	lactated ringer's infusion 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	lactated ringer's infusion 250 mL	Dose: 250 mL	Route: intravenous	continuous @ 30 mL/hr				Instructions:	To keep vein open			Chemotherapy
  	sipuleucel-T-lactated ringers (PROVENGE) 50 million cell/250 mL infusion (RESTRICTED) 250 mL	Dose: 250 mL	Route: intravenous	once over 60 Minutes for 1 dose	Start: S	End: S		Instructions:	Do not use PROVENGE until confirmation of product release is received from Dendreon. Do not use a cell filter.

Dendreon will send the Final Product Disposition Notification form containing the patient identifiers, expiration date and time, and the disposition status (approved for infusion or rejected), to the infusion site. Infusion must begin prior to the expiration date and time indicated on the Final Product Disposition Notification form and Product Label. Do not use expired PROVENGE. Keep the sealed, patient-specific PROVENGE infusion bag within the insulated polyurethane container inside the outer cardboard shipping box until the time of administration.

Observe the patient for acute infusion reactions for at least 30 minutes following each infusion. If acute infusion reactions occur, such as chills, fatigue, fever, nausea, and joint ache, interrupt or slow the infusion and administer appropriate medical treatment as needed. If the infusion is interrupted, keep the PROVENGE infusion bag at room temperature. Do not resume infusion if the PROVENGE infusion bag has been at room temperature for more than 3 hours.

Do not administer if the bag leaks during handling, is damaged, or if clumps remain in the bag.			PRN Medications
  	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once PRN	Start: S				  	promethazine (PHENERGAN) 12.5 mg in sodium chloride 0.9% 10 mL injection	Dose: 12.5 mg	Route: intravenous	once PRN	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	PROMETHAZINE 25 MG/ML INJECTION SOLUTION	Medications	12.5 mg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	Base	10 mL	Always	Yes			  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S					PRN Medications
  	alteplase (CATHFLO) for Quinton and Hemodialysis Catheters 2 mg	Dose: 2 mg	Route: intra-catheter	once PRN	Start: S			Instructions:	Instructions:  Notify MD.  Draw labs via peripheral vein access.  Hold and notify MD   if platelet count is less than 50,000. 
2 mg dose of Cathflo is for Quinton and Hemodialysis Catheter Clearance.			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