Unique Plan Description: ONC Hodgkins NonHodgkins Lymphoma Stem Cell Transplant
Plan Selection Display: ONC Hodgkins NonHodgkins Lymphoma Stem Cell Transplant
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2022-09-19 10:40:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-06-26 09:07:58
Available at all facilities: Yes

Admission
Admit/Discharge/Transfer
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
Vital Signs
	Vital Signs
		Q4H-Sch
			Comment: Strict - whether sleeping or not
Activity
	Activity-As Tolerated
		T;N, Ok to walk in halls with mask
Diet
	Regular Diet
		T;N
			Comment: Patient in protective environment
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, Q24H, spec type = Blood
	Basic Metabolic Panel
		T+1;0400, Routine, Tue, spec type = Blood
		T+1;0400, Routine, Wed, spec type = Blood
		T+1;0400, Routine, Fri, spec type = Blood
		T+1;0400, Routine, SatSun, spec type = Blood
	Comprehensive Metabolic Panel
		T+1;0400, Routine, Mon, spec type = Blood
		T+1;0400, Routine, Thu, spec type = Blood
	Magnesium Level
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, Thu, spec type = Blood
		T+1;0400, Routine, Mon, spec type = Blood
	Phosphorus
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, Mon, spec type = Blood
		T+1;0400, Routine, Thu, spec type = Blood
	LDH
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, Mon, spec type = Blood
		T+1;0400, Routine, Thu, spec type = Blood
	Uric Acid
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, Mon, spec type = Blood
		T+1;0400, Routine, Thu, spec type = Blood
	Prealbumin
		T+4;0400, Routine, spec type = Blood
	COVID-19 (2019 Novel Coronavirus) by PCR
		T;N, Stat, spec type = Nasopharynx
	Pregnancy Test Urine
		T;N, Stat, Stat, spec type = Urine
Diagnostic Tests
Radiology
	Chest 1 View
		Routine
Medications

	acyclovir
		800 mg, Tab, By Mouth, BID, Indication: Prophylaxis
	fluconazole
		400 mg, Tab, By Mouth, DAILY, Indication: Prophylaxis
	magic mouthwash
		5 mL, Suspension, Mouthwash, QID
			Comment: Swish and Spit. Administer prior to chlorhexidine.
		5 mL, Suspension, Mouthwash, Q1H, PRN discomfort
			Comment: Swish and Spit
	chlorhexidine 0.12% oral rinse
		15 mL, Solution, Mouthwash, BIDPC
			Comment: Swish and gargle for 30 seconds then expectorate. Administer after magic mouthwash.
	acetaminophen
		650 mg, Tab, By Mouth, Q6H, PRN for headaches
			Comment: or pain
	melatonin
		3 mg, Tab, By Mouth, QHS, PRN insomnia
		Less than 65 years old(NOTE)*
	OLANZapine
		5 mg, Tab, By Mouth, QHS, T+5, duration: 4 Day(s)
			Comment: start day -1/day of admission; give on days -1, 0(transplant day), 1, and 2.
		65 years or greater(NOTE)*
		2.5 mg, Tab, By Mouth, QHS, T+5, duration: 4 Day(s)
			Comment: start day -1/day of admission; give on days -1, 0(transplant day), 1, and 2.
	ondansetron
		8 mg, Tablet-Disintegrating, By Mouth, Q8H, PRN nausea, T+1;N
			Comment: Begin on day 0/stem cell transplant day
		8 mg, Injection, IV Push, Q8H, PRN nausea, T+1;N
			Comment: Begin on day 0/stem cell transplant day; only if unable to take PO
	prochlorperazine
		10 mg, Tab, By Mouth, Q6H, PRN nausea
			Comment: For nausea refractory to ondansetron
	LORazepam
		1 mg, Tab, By Mouth, Q4H, PRN nausea
			Comment: For nausea associated with anxiety
	LORazepam Injectable
		0.5 mg, Injection, IV Push, Q4H, PRN nausea
			Comment: For nausea associated with anxiety
	meclizine
		25 mg, Tab, By Mouth, DAILY, PRN nausea
			Comment: For nausea associated with motion sickness
	filgrastim
		10 mcg/kg, Solution, SUBCUTANEOUS, Q24H, T+10;1200
			Comment: To start on Day +4 post transplant. Dose is rounded to the nearest vial size
	alteplase - CathFlo
		1 mg, Injection, IV Push, DAILY, PRN to maintain patency, duration: 2 Dose(s)/Time(s)
			Comment: Instill into occluded Central Venous Catheter and allow to sit for 30 minutes, then assess catheter function by aspirating.  If not restored, allow 90 additional minutes of dwell time and reassess.  If still unsuccessful then repeat dose one time only.
	loperamide
		2 mg, Capsule, By Mouth, Q1H, PRN diarrhea
			Comment: Give 2 capsules after the first loose stool, then 1 capsule after each loose stool. Maximum 8 capsules per day. Give only if C. difficile result negative.
	enoxaparin
		40 mg, Syringe, SUBCUTANEOUS, DAILY
			Comment: start day of admission. hold when platelet less than 30,000
Patient Care
	Resuscitation Status
		Full Code
		No Code
	VTE Advisor
		Medical
	Do not give medication
		T;N, enoxaparin if platelets less than 30,000.
	Isolation Precautions
		T;N, Protective, Reason for Isolation: Immune suppressed
	Weight
		T+1;1600, Q24H
			Comment: Strict - whether sleeping or not
	Incentive Spirometer
		Q2H
	Order Lab
		Blood Culture Set if temp >/= 101 or a sustained temp >/= 100.5 and notify physician/PA
		Procalcitonin level with first fever
	Notify MD of Lab results
		if magnesium <1.7, or > 2.6 mg/dl; if potassium <3.5 or >5.5 mmol/L; if phosphorus <2.5 or >4.5 mg/dL
	Notify MD
		Dr. Tarantolo's cell phone: 402-681-9914. Use this number for his transplant patients only.
	IV-Maintain
		
	Communication to HOSPITAL RN
		Verify patient has received Covid-19 vaccine
	Order/Transfuse Blood Product
		T;N, Packed cells, 1 unit
			Comment: For hgb <7grams/dL. Use irradiated and leukocyte reduced products. Enter order for: acetaminophen 650mg PO once prior to transfusion and diphenhydramine 25mg PO once prior to transfusion
		T;N, Platelet, 1 unit
			Comment: For platelet count < or = 10,000. Use irradiated & leukocyte reduced product. Enter order for: acetaminophen 650mg PO once prior to transfusion and diphenhydramine 25mg PO once prior to transfusion
	Notify MD
		If >3 liquid stools in 24 hours, notify MD for diarrhea treatment, and enter order for Enhanced contact precautions
Therapies
	Consult Physical Therapy, Evaluate and Treat
		Reason to See: Evaluate and Treat
			Comment: Order Dx: Hodgkins NonHodgkins LymphomaStem cell transplant patient. See as needed throughout hospitalization
	Pulse Oximetry Spot Check RT
		BID
			Comment: Strict - whether sleeping or not
	Consult Occupational Therapy, Evaluate and Treat
		Reason to See: Evaluate and Treat
			Comment: Order Dx: Hodgkins NonHodgkins Lymphoma, Stem cell transplant patient
	Therapeutic Recreation Eval and Follow
		Evaluate and followup
			Comment: Stem Cell Transplant patient.  Order Dx: Hodgkins NonHodgkins Lymphoma
Consults/Follow-up
	Consult Social Work
		Evaluation
	Consult Dietitian
		Regarding: Nutrition Assessment
			Comment: dietician to see frequently throughout hospitalization. Stem Cell Transplant patient
	Consult Infectious Disease
		Reason for Referral: Non Hodgkins Lymphoma Stem Cell patient, Refer to/Consult with: Dr. Penn
	Pharmacy Consult
		Discontinue enoxaparin when platelets less than 30,000. Resume when platelets recover to >30,000

Chemotherapy
Vital Signs
	Vital Signs
		T+5;1130
			Comment: Take vital signs prior to and following melphalan
IV Solutions
	Sodium Chloride 0.9%
		1,000 mL, IV, T+5; 0600, 1 Dose(s)/Time(s), 250 ml/hr
			Comment: Give on day -1 prior to melphalan.  Administer over 4 hours.
		1,000 mL, IV, T+5;1000, 1 Dose(s)/Time(s), 125 ml/hr
			Comment: Give day -1 (day of admission) through central line during melphalan infusion and continue for 30 minutes after melphalan infusion completed
Medications
	palonosetron
		0.25 mg, Injection, IV Push, Q48H, T;0930, duration: 3 Dose(s)/Time(s)
			Comment: Push over 30 seconds. Give on days -6, -4, and -2.
	dexAMETHasone
		10 mg, INT, IVPB, Q24H, T;0930, duration: 6 Day(s)
	fosaprepitant
		150 mg, INT, IVPB, Once, infuse over 30 min(s), T;0930
			Comment: Give on Day -6, Begin 30 min prior to carmustine
	carmustine/D5W 1000 mL
		300 mg/m2, INT, IVPB, Q2H, T;1000, 1 Dose(s)/Time(s), Infuse Over 2 hr
			Comment: Total dose: _________ Date of Administration:_________(BiCNU). Administer in non-PVC bags on day -6.
		50 mL, EVERY BAG
		1,000 mL, EVERY BAG
	etoposide/NS 500 mL
		100 mg/m2, IVPB, Q12H, T+1;1000, 8 Dose(s)/Time(s), Infuse Over 60 min(s)
			Comment: Infuse Day -5 to -2. Total dose: _________ Date of Administration:_________
		50 mL, EVERY BAG
		500 mL, EVERY BAG
	cytarabine/NS 500 mL
		100 mg/m2, IVPB, Q12H, T+1;1100, 8 Dose(s)/Time(s), Infuse Over 60 min(s)
			Comment: Infuse day -5 to -2. Total dose: ___________ Date of administration: __________
		50 mL, EVERY BAG
		500 mL, EVERY BAG
	melphalan injectable
		140 mg/m2, Injection, IVPB, Once, T+5;1000
			Comment: Total dose ___________ date of administration _____.  To be given through central line on day -1, to run over 20 minutes.  Flush IV line with normal saline after completion of infusion. Patient to suck on ice or popsicles for 20 minutes prior to, during and for 20 minutes after melphalan.Actual Weight: _____ Ideal Weight: _______ Adjusted body weight:______ Height:______ BSA:_________

Stem Cell Infusion
IV Solutions
	Sodium Chloride 0.9%
		1,000 mL, IV, T+6;1200, 1 Dose(s)/Time(s), 100 ml/hr
			Comment: Run through central IV line during stem cell infusion. Discontinue when stem cell infusion done.
	sodium bicarbonate 100 mEq/D5W 1000 mL
		100 mEq, IVPB, Q4H, 250 ml/hr, T+6;0800, duration: 2 Dose(s)/Time(s)
			Comment: Start 4 hours prior to stem cell infusion and continue 4 hours after transplant.
		900 mL, EVERY BAG
Medications
	diphenhydrAMINE
		25 mg, Injection, IV Push, Once, T+6;1130
			Comment: Premedicate 30 minutes prior to stem cells.
	LORazepam Injectable
		1 mg, Injection, IV Push, Once, T+6;1130
			Comment: Premedicate 30 minutes prior to stem cells.
	meperidine
		25 mg, Syringe, IV Push, Q2H, PRN see comment, T+6;1330, duration: 8 hr
			Comment: for chills and rigors.  Begin 2 hours after 30 minute premed dose and continue until 4 hours after infusion.
		25 mg, Syringe, IV Push, Once, T+6;1130
			Comment: premedicate 30minutes prior to stem cells
	hydrocortisone
		100 mg, Injection, IV Push, Once, T+6;1130
			Comment: premedicate 30 minutes prior to stem cells
	furosemide
		20 mg, Injection, IV Push, Once, PRN see comment, T+6;N
			Comment: If patient has not voided within 1 hour of bladder scan.  If volume is less than100mL, give furosemide 20mg IV push.
Patient Care
	Obtain supplies/equipment
		T+6;0900, oxygen tubing, nasal cannula set up, 2 sets of secondary tubing, warm water bath and dynamap.  Place at bedside on transplant day.
			Comment: Place at bedside on transplant day.
	Intake and Output
		T+6;0800, Q1H
			Comment: until 4hr post stem cell infusion. If patient has not voided within the hour, bladder scan and record.
	Bladder Scan
		T+1;1300, Assess for Residual. PRN as needed  if patient has not voided within hour during and for 4 hours after stem cell infusion
	Notify MD
		T+6;1400, if patient has not voided within hour during and for 4 hours after stem cell infusion
	Replace fluid volume deficit
		T+6;1300, increase hydration to replace ml for ml if output greater than intake by 100 ml or more on any given hour
	Notify MD
		T+6;1600, for further hydration orders if urine heme(+) 4 hours after stem cell infusion complete.
	Order Lab
		T+6;1200, BMP to be drawn at end of transplant.
		T+6;1200, Urogram - 4 hours after stem cells infused.  (This test includes urine hematest)
	Stem Cell Infusion
		T;N
			Comment: Date:               Time:                       # of bagsInstructions:
Therapies
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
			Comment: with stem cell infusion and PRN
Non Categorized
		Begin Infusion of stem cells on __/__/____@__:__,  ___bags.  FYI:  Stem Cells usually given at 12:00(NOTE)*

CHEMO Reaction Protocol
Vital Signs
	Vital Signs
		Assess vital signs every 2 to 5 minutes until the patient is stable. Place patient into a recumbent position with elevation of the lower extremities if hypotensive
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		Reassess vital signs every 15 minutes x 2, then q30min x 2, or more frequently as needed, I&O, etc until stable
Activity
	Position Patient
		T;N
			Comment: If hypotensive, keep patient supine with legs elevated or bed in Trendelenburg.
IV Solutions
	Sodium Chloride 0.9% IVPB
		500 mL, Solution-Injection, IVPB, DAILY, PRN see comment, 999 ml/hr
			Comment: for reaction to chemotherapy
		1,000 mL, Solution-Injection, IVPB, DAILY, PRN see comment, 999 ml/hr
			Comment: for reaction to chemotherapy
Medications
	Benadryl
		50 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy
		25 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy
	Decadron (MH/WH)
		20 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy, 1st choice steroid
	SOLU-Medrol
		125 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy, 2nd choice steroid
	Solu-CORTEF
		100 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy, 3rd choice steroid
	EPINEPHrine
		0.5 mg, Injection, SUBCUTANEOUS, DAILY, PRN see comment
			Comment: for hypersensitivity reaction not resolved by diphenhydramine and/or anaphylactic				reactions to chemotherapy, may repeat every 10 minutes for up to 3 doses
		0.5 mg, Injection, IM-Intramuscular, DAILY, PRN see comment
			Comment: for hypersensitivity reaction not resolved by diphenhydramine and/or anaphylactic				reactions to chemotherapy, may repeat every 10 minutes for up to 3 doses
	meperidine
		25 mg, Syringe, IV Push, Once, PRN for see comment
			Comment: For chills and rigors
Patient Care
	Notify MD
		T;N, Contact the oncologist if any of the reaction protocol medications are administered to the patient.

scopolamine (Transderm-Scop) 1 mg patch
Medications
	Transderm-Scop 1 mg patch
		1 mg, Patch, TOPICAL, Q3D
	scopolamine Patch Removal
		Patch Removal, Patch, TOPICAL, Q3D, T+3;0900
Patient Care
	Medication patch site check
		T;N+720, Q12H

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase