Bone Marrow Transplant Admission Orders: ALLOgeneic Hematopoietic Stem Cell Transplant Patients Page 1 of 5

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1 ALLOgeneic Hematopoietic Stem Cell Transplant Patients Page 1 of 5 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 NOR HT: in WT: kg BSA: m 2 Karnofsky: PRECATIONS: Protective Precations. Mask and hand washing or gloves prior to each entry into patient room Patient may not leave the nit nless OK with MD, and with AFB mask, gown and shoe covers 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 STAT / TODAY / IN AM MD Signatre: Date: Time: RN Signatre: Date: Time:

2 ALLOgeneic Hematopoietic Stem Cell Transplant Patients Page 2 of 5 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, soft reglar (do not chop meats) Other: Conslt Registered Dietitian (RD) for ntrition management per RD RD may modify/manage diet order and/or enteral ntrition per approved MNT protocol 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 Retic Cont CMP GGT PO 4 Mg PT PTT ric Acid /A Serm Qantiferon Gold Assay Type and Screen Other: LABS (recrrent): Crossmatch with donor prodct Day 0 / / 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, PO 4 and Mg Q Monday, Wednesday and Friday BMP Q Tesday, Thrsday, Satrday and Snday GGT and PT/PTT Q Monday See order sheet for Bslfan (Bslfex) levels arond dose # 1 / / Cyclosporine trogh levels on Day 1 / /, Day +1 / /, Day +3 / /, then Q Monday, Thrsday. This is to be drawn jst before 9:00 am dose on each day. Call reslts. ** Cyclosporine levels are only to be drawn from red lmen or lateral port lmen ** Serm galactomannan and fngitell assays beginning day +7 / / and Q Monday thereafter Draw CMV DNA beginning Day +14 / / and q Monday thereafter. Call all positive reslts immediately to MD. Portable CXR QTes at 06:00 beginning the week following admission. Begin / / 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: MD Signatre: Date: Time: RN Signatre: Date: Time:

3 ALLOgeneic Hematopoietic Stem Cell Transplant Patients Page 3 of 5 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: Standard Medication Orders: Schedled Meds NO TYLENOL (acetaminophen) or TYLENOL CONTAINING PRODCTS to be given with the exception of Day 0 premed for transplant ( / / ) withot transplant MD approval. B12 (cyanocobalamin) 1 mg sq on admission, then day +20 ( / / ). Alloprinol (Zyloprim) 600 mg po on admission and 300 mg PO bid for 5 days. D/C after doses on ( / / ). Antimicrobials Bactrim DS (slfamethoxazole and trimethoprim) 800mg/160mg tablet PO BID on days 5 ( / / ), -4 ( / / ), and 3 ( / / ) Day 0, ( / / ) begin Vancomycin 1500 mg/m 2 x m 2 = mg (not to exceed 2,500 mg) IV at 04:00. Repeat at 16:00 and Q 16:00 thereafter. This is for prophylaxis only for patients with established gram positive infection. Conslt for pharmacokinetic monitoring. D/C with first ANC > 1,000 post nadir. On Day + 14 ( / / ) Conslt MD re: initiation of Penicillin VK 250 mg PO BID. If Pencillin VK ordered D/C day +30 ( / / ). Levaqin (levofloxacin) 500 mg PO daily beginning day -3 ( / / ). Nrsing to obtain order to D/C when IV antibiotics begin other than Vancomycin/ Tobramycin. Valacyclovir (Valtrex) 1gm PO TID, beginning day -3 ( / / ). D/C Day +100 ( / / ). Sbstitte Acyclovir (Zovirax) 250mg/m 2 x m 2 = mg IV q 8h if nable to take PO. Discontine if Ganciclovir (Cytovene) is begn. Voriconazole (VFEND) 6mg/kg IV q 12 hrs x 2, then 200mg po q 12 hrs, begin Day 1 ( / / ). MD Signatre: Date: Time: RN Signatre: Date: Time:

4 ALLOgeneic Hematopoietic Stem Cell Transplant Patients Page 4 of 5 Standard Medication Orders: Schedled Meds Filgrastim (Nepogen) 5mcg/kg/day = mcg sq. (max = 480 micrograms) daily Begin day +5 ( / / ). Discontine when ANC >1,000 for 2 consective days. Do sbstitte with Tbo-Filgrastin (Granix) Slfamethoxazole -Trimethoprim (Bactrim SS) 400mg/80mg PO daily beginning Day +30 ( / / ). D/C on Day +100 ( / / ) nless nder treatment for GvHD. Heparin 100 nits/kg/day = 100 nits X kg = nits/day continos IV infsion. ( cc/hr). se heparin 25,000 nits in 250 ml D 5 W. Begin with first chemotherapy and discontine on Day +30 ( / / ). Enoxaparin (Lovenox) mg SQ Q12 hors. D/C on Day +30 ( / / ). rsodiol (Actigall) 300 mg PO TID, D/C after doses on Day +30 ( / / ) if bilirbin < 2.0. Cyclosporine (Sandimmne) 2.5 mg/kg x kg = mg IV in 100cc NS over 2 hors Q12 hors (09:00 and 21:00) beginning Day 3 ( / / ) to Day 1 ( / / ). On Day 0 ( / / ) begin 1.5 mg/kg x kg = mg IV q 12 hors ** Cyclosporine mst only be infsed via ble lmen or medial port lmen ** Mycophenolate Mofetil (Cellcept) 500 mg PO TID beginning day +1 ( / / ). D/C on day +100 ( / / ). May sbstitte 500 mg IV if nable to take PO. ATGAM Premed for Lymphocyte Immne globlin (ATGAM ) with Ibprofen 400 mg PO, Benadryl 25 mg IV, and Solmedrol 1 mg/kg X kg = mg IV. Platelet cont one hor after each ATGAM infsion Lymphocyte Immne globlin (ATGAM ) 15 mg/kg actal body weight X kg = mg IV at 14:00 on Day 4 / /, Day 3 ( / / ), Day 2 ( / / ) and Day 1 ( / / ). Administer Solmedrol 1 mg/kg X kg = mg prior to ATGAM infsion. Rn first 50 cc of ATGAM over 1 hr. Total infsion time 4-6 hors. Additional doses of Lymphocyte Immne globlin (ATGAM ) day +1 ( / / ) and day +3 ( / / ) for 5/6 Ag match or if infsed T lymphocyte dose > 5 X 10 5 CD3+ cells /kg recipient weight Oral Care Biotene 15 ml swish and expectorate QID Chlorhexidine Glconate 0.12% (Peridex) 15 ml swish and expectorate BID. MD Signatre: Date: Time: RN Signatre: Date: Time:

5 Bone Marrow Transplant Admission Orders Allogeneic Hematopoietic Stem Cell Transplant Patients Page 5 of 5 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 Q12 hrs. Conslt MD for d/c on Day +1 ( / / ) Frosemide (Lasix ) 20 mg IV Q12 hrs PRN for weight > kg. Analgesia: OxyCONE (Roxicodone) 5-10 mg PO Q4hrs PRN moderate to severe pain (>4) 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) 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 6 hrs PRN If nasea refractory to medications listed above Granisetron (Kytril) 1mg IV Q 24 hors PRN 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 100ml NS via IV continos infsion Q 8h. (approximate rate of 13 ml/hr) Gastrointestinal: Maalox 30 ml PO Q 2 hrs. PRN dyspepsia. Loperamide (Imodim ) 2-4 mg PO PRN each loose stool, once C. difficile confirmed as negative. Max dose of16mg/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 : OTHER ORDERS: MD Signatre: Date: Time: RN Signatre: Date: Time:

6 + + BMT STANDARD TRANSFSION Orders Patient Identifier Do t se Abbreviations q.d.,qd q.o.d. qod Every Other Day 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 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 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*

7 [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 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. 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*