Bone Marrow Transplant Admission Orders: AUTOlogous Hematopoietic Stem Cell Transplant Patients Page 1 of 4

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1 ATOlogos Hematopoietic Stem Cell Transplant Patients Page 1 of 4 Abbreviations ADMISSION: See Patient Stats Certification Order already completed by MD niversal Patient Care Orders: Initiate Rapid Response Team/Stroke Team as appropriate and notify patient s MD of condition. Initiate Emergency Resscitation per ACLS gidelines ntil Code Team arrives. Initiate Hypoglycemia Protocol for BG <70 mg/dl BED TYPE: BMT nit. Room : DIAGNOSIS: ALLERGIES: PLAN- High Dose Chemotherapy: BMT Day 0 ( / / ) Every Other Day PATIENT ALLERGIES ABO/Rh CMV/IgG 0 4 nits HT: in WT: kg BSA: m 2 Karnofsky: PRECATIONS: Protective Precations. Hand washing or gloves prior to each entry into patient room CODE STATS: Fll Code ACTIVITY: Encorage physical activity. May se treadmill or exercise bike if platelet cont >50,000. If compromised, conslt PT. Conslts: Therapy: Physical Occpational Wond Case Manager/DC Planner re: to see: Vitals/Patient Monitoring Vital Signs Q4h tify attending MD for any new temp (first in past 24 hors) 100.5F Other : NRSING INSTRCTIONS Strict I & O Q12h Measre: weight Q12h Incentive spirometry for times daily after moth care. se only fragrance, color and preservative-free prodcts for skin and rectal care PRN MD Signatre: Date: Time: STAT / TODAY / IN AM RN Signatre: Date: Time:

2 ATOlogos Hematopoietic Stem Cell Transplant Patients Page 2 of nits ORAL CARE Toothettes or ltra-soft toothbrsh only. Refer to BMT Oral Care Standard se the Oral Assessment Gide and Docment the score pon admission and Q12 hrs. Brsh teeth BID and se Peridex and Biotene oral rinses as ordered NTRITION / DIET: Netropenic reglar Other: GLCOSE MONITORING: Initiate Blood Glcose Monitoring QAC and QHS See completed Glycemic Control Order Set- for inslin orders All Blood Glcose Levels are to be drawn from the central venos line Initiate Hypoglycemia protocol if BG <70 and notify MD RESPIRATORY Plse Ox: with VS Hmidify all O2 LABS ON ADMISSION: CBC CMP GGT PO 4 Mg PT PTT /A Type and Screen Other: LABS (recrrent): Peri-Rectal swab for VRE and Bilateral nares swab for MRSA on admission and Q Monday while hospitalized (per Infection Control protocol). CBC daily throgh nadir. Add differential daily x 3 days beginning with the first WBC > 1,000. CMP and Mg Q Monday, Wednesday and Friday BMP Q Tesday, Thrsday, Satrday and Snday PO 4 Q Monday Fecal occlt blood on all stools and dipstick rine for blood daily Implement C. Diff protocol if three (3) watery stools in 24 hors Other: IV CARE May access and se implanted venos port. Rotine Central Venos Catheter care. Maintain occlsive dressing. See PICC Line Orders IMPORTANT: PICC Catheter to be secred with Coban dressing over forearm Hickman Catheter to be looped and secred to top of dressing at all times VTE RISK AND PREVENTION MODERATE-HIGH RISK: Bilateral Seqential Compression Devices SCDs Anticoaglation Contraindicated becase: High risk of bleeding On other therapetic anticoaglation Other: MD Signatre: Date: Time: RN Signatre: Date: Time:

3 ATOlogos Hematopoietic Stem Cell Transplant Patients Page 3 of nits Standard Medication Orders: Schedled Meds Filgrastim (Nepogen) 5mcg/kg/day = mcg sq. (max = 480 micrograms) daily Begin Day +3 ( / / ). Discontine when ANC >1,000 for 2 consective days. Do sbstitte with Tbo-Filgrastin (Granix) Biotene 15 ml swish and expectorate QID. Chlorhexidine Glconate 0.12% (Peridex)15 ml swish and expectorate BID. Acylovir (Zovirax) 400 mg PO b.i.d beginning Day -1 ( / / ). If nable to take PO, sbstitte Acyclovir 125 mg/m 2 x m 2 = mg IV Q 8hrs. Infse over one hor. Levofloxacin (Levaqin) 500 mg 750 mg PO daily beginning when WBC < 1,500 Flconazole (Diflcan) 400 mg PO x 1, then 200 mg PO daily with first WBC < Zyloprim (Alloprinol) 600 mg PO on admission and 300 mg PO bid for 5 days Heparin 100 nits/kg/day = 100 nits X kg = nits/day continos IV infsion. ( ml/hr) se heparin 25,000 nits in 250 ml D 5 W. Begin with first chemotherapy rsodiol (Actigall) 300 mg PO TID, D/C after doses on Day +30 ( / / ). Standard Medication Orders: n-schedled (PRN) Meds Start Pamine at 3 micrograms/kg/min continos IV infsion for wt of > kg. (May contine rotine vital signs.) Conslt physician for d/c on Day +1 ( / / ). If, 12 hrs following the initiation of Pamine wt is still > kg and last creatinine is < 2.0, start Frosemide (Lasix ) 20 mg IV Q 12 hrs. Conslt MD for d/c on Day +1 / / ) Frosemide (Lasix ) 20 mg IV Q 12 hrs PRN for weight > kg. Analgesia: Acetaminophen (Tylenol) 650 mg PO Q4 hrs PRN mild pain (1-3) (Max dose Tylenol 4 g / 24 hrs) OxyCONE (Roxicodone) 5-10 mg PO Q4hrs PRN moderate to severe pain (>4) Gastrointestinal: Maalox 30 ml PO Q 2 hrs. PRN dyspepsia. Loperamide (Imodim ) 2-4mg PO PRN each loose stool, once C. difficile confirmed as negative. Max dose of 16mg/day. Magic mothwash, ml, swish and expectorate or swallow for mcositis pain Q 2 hrs PRN Polyethylene Glycol (MiraLAX) 17g. dilted in 8 onces of water or jice PO Q 24 hors PRN for constipation OR Other Laxative : MD Signatre: Date: Time: RN Signatre: Date: Time:

4 ATOlogos Hematopoietic Stem Cell Transplant Patients Page 4 of 4 nits Nasea and Vomiting Algorithm: (if checked).: First Line treatment for Nasea: Ondansetron (Zofran) 4-8 mg IV Q 6 hrs PRN Initial Treatment Ineffective: Promethazine (Phenergan): mg IV or PO Q 4 hrs PRN If Phenergan Ineffective: (Choose one medication from list) Lorazapam (Ativan) mg IV or PO Q 4 hrs PRN Diphenhydramine (Benadryl) 25 mg IV or PO Q 4 hrs PRN Prochlorperazine (Compazine) 10 mg IV or PO Q 6 hrs PRN Metoclopramide (Reglan) mg IV or PO Q 4 hrs PRN Antivert (Meclizine) 25 mg PO PRN. Once started, contine 25mg PO q 12 hrs x 48 hrs Scopolamine patch 1.5mg transdermal patch Q 72 hrs PRN for motion sickness For persistent ncontrolled nasea with meds listed above: Begin BAD drip consisting of Diphenhydramine (Benadryl) 50 mg, Lorazepam (Ativan) 1 mg and Dexamethasone (Decadron) 6 mg in 100 NS ml IV continos infsion Q 8h. (approximate rate of 13 ml/hr) OTHER ORDERS: MD Signatre: Date: Time: 0 4 RN Signatre: Date: Time:

5 + + BMT STANDARD TRANSFSION Orders Patient Identifier Do t se Abbreviations q.d.,qd q.o.d. qod Every Other Day nits TRANSFSION PARAMETERS: All transfsions are to be Irradiated to 2500cGy and Lekodepleted All transfsions are to be: (Check One) CMV seronegative CMV seronegative preferred CMV nscreened PRBC TRANSFSIONS: Type, Crossmatch and Transfse nits of PRBC s Admission for Myeloablative therapy and Transplantation Any Hgb of < 10g/dL prior to transplant Any Hgb of < 8g/dL post-transplant Other Admissions: Indications HCT 21% or Hbg 7 gm/dl HCT 24% or Hbg 8 gm/dl; with CAD and nstable angina / MI / cardiogenic shock 30-40% of estimated blood volme (> ml) lost; not responding to volme resscitation rmovolemic; with the need for increased oxygen carrying capacity 0 4 PLATELET TRANSFSIONS: Transfse 1 nit of single donor apheresis platelets STAT for: Any platelet ct < 10,000/mm 3 A platelet ct of 11,000-20,000/mm 3 prior to BM Biopsy or other invasive procedres A platelet ct greater than 20,000/mm 3 in the presence or to control major bleeding complications. PREMEDICATIONS: If patient is receiving Lasix per admission orders protocol, give additional Frosemide (Lasix ) 20 mg IV immediately prior to first nit of PRBCs Diphenhydramine (Benadryl) 25 mg IV or PO 30 mintes prior to transfsion x 1 Acetaminophen (Tylenol) 650 mg PO 30 mintes prior to transfsion x 1 Methylprednisolone (Sol-Medrol) mg IV 30 mintes prior to transfsion x 1 LABS: One hor post all platelet transfsions draw a platelet cont. Call MD if < 20,000. MD Signatre: Date: Time: Originated: Revised: 1/08;4/09; 3/10, 8/11, 1/14; 10/14; 2/15 RN Signatre: Date: Time: *1016*

6 [Patient Identifier] BMT nit: Electrolyte Replacement Protocol Do t se Abbreviations Potassim replacement for hypokalemia: For K+ level 3.2 to 3.5: KCl 40 meq PO X 1 dose If nable to take orally: give KCl 40 meq IV over 2 hrs X 1 Repeat K+ level 24 hors later. q.d.,qd For K+ level of 2.8 to 3.1: KCl 40 meq PO Q4 hrs X 2 doses If nable to take orally: give KCl 60 meq IV over 3 hors If inpatient, repeat K+ level 12 hors later q.o.d. qod Every Other Day For K+ level < 2.8: replacement for hypomagnesemia: Redraw STAT K+ level and Immediately begin KCl 80 meq IV over 4 hors Repeat K+ level immediately after infsion nits For level 1.0 to 1.5: 4 grams IV over 3-4 hors Repeat level 24 hors later For level < 1.0: Calcim replacement for hypocalcemia: For corrected calcim < 8.5: Phosphors replacement for hypophosphatemia: slfate 6 grams IV over 4-6 hors If inpatient, repeat level 12 hors later Calcim Glconate 2 grams IV over 4 hors Repeat Ca level in 24 hors For PO 4 below normal (< 2.5): Potassim Phosphate and Sodim Phosphate (Phos-NaK) or eqivalent 1 packet PO TID X 3 doses If nable to take PO: NaPO mmol IV over 2-3 hrs. 0 4 If NaPO 4 is navailable, may sbstitte K-Phos 10mmol IV over 2-3 hors. ( sbstitte if Potassim is >4.5MEq/L Call MD for new orders) Repeat PO 4 level in 24 hors tes: All labs above are in addition to any standing lab orders. May combine infsions if more than one PRN replacement order criteria are met. Always administer in lowest safe volme. If an otpatient, call MD for any replacement reqiring a 12 hor repeat lab. MD Signatre: Date: Time: RN Signatre: Date: Time: Originated: Revised:1/08;4/09;5/09; 3/10, 8/11, 2/14 *1230*