Autologous Marrow and Peripheral Blood Stem Cell (PBSC) Admission [30400149] If appropriate for patient condition, please consider the following order sets: - Oncology Series Blood and Blood Product Transfusion #728 - Autologous Marrow and Peripheral Blood Stem Cell (PBSC) Re-infusion #150 - Electrolyte Replacement: Med/Surg, Med/Surg Tele #842
Height______Weight______Allergies______
General
Admission/Level of Care [127413]
[ ] Admit to Inpatient [ADT1] ______REQUIRED Diagnosis: Estimated length of stay: Certification: I reasonably expect the patient will require inpatient services that span a period of time over two-midnights. (See Rationale Section in the order for options) Additional documentation will be found in progress notes and admission history and physical. Must be completed by Physician for Inpatient Admissions: Rationale for Inpatient Admission: Plans for post hospital care: See Discharge Summary/ Progress Note Level of Care:
[ ] Refer to Observation [ADT12] ______REQUIRED Diagnosis: Monitor for: Notify provider when: Level of Care:
Vital Signs [128399]
[ ] Vital signs [NUR490] Routine, Every shift
[X] Vital signs [NUR490] Routine, Every 4 hours
[ ] Vital signs (specify other frequency) [NUR490] Routine, Every 4 hours
[ ] Cardiac monitoring [NUR436] Routine, Continuous For Until specified
[ ] Orthostatic blood pressure [NUR478] Routine, Once, If symptomatic.
Provider’s Initial:
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[X] Pulse Oximetry [NUR585] Routine, Per unit routine Keep O2 saturation greater than or equal to: With vital signs.
Activity [128404]
[ ] Activity as tolerated [NUR129] Routine, Until discontinued, Starting S
[ ] Up with assistance [NUR131] Routine, As needed
[X] Daily shower [NUR550] Routine, Until discontinued, Starting S
Diet [171306]
[ ] Diet NPO [DIET41] Diet effective now, Starting S NPO Except: Diet Comments:
[ ] Diet Cardiac [DIET44] ______REQUIRED Diet effective now, Starting S Select/Nonselect: Additional Modifiers: Low Fat Viscosity/Liquids: Texture: Fluid Restriction / day: Supplements:
[ ] Diet Liquid [DIET42] Diet effective now, Starting S Diet: Clear Diet: Additional Modifiers: Viscosity/Liquids:
[ ] Diet Liquid [DIET42] Diet effective now, Starting S Diet: Full Diet: Additional Modifiers: Viscosity/Liquids:
[X] Diet General [DIET24] Diet effective now, Starting S Select/Nonselect: Select Additional Modifiers: Viscosity/Liquids: Texture: Fluid Restriction / day: Sodium Modifiers: Supplements:
Provider’s Initial:
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[ ] Diet Diabetic [DIET16] ______REQUIRED Diet effective now, Starting S Diet, Diabetic: Select/Nonselect: Additional Modifiers: Viscosity/Liquids: Texture: Fluid Restriction / day: Sodium Modifiers: Supplements: Total Calories:
[ ] Diet Neutropenic (when ANC is less than 500) ______REQUIRED [DIET24] Diet effective now, Starting S Select/Nonselect: Additional Modifiers: Neutropenic Viscosity/Liquids: Texture: Fluid Restriction / day: Sodium Modifiers: Supplements:
Nursing Intervention [128406]
[X] CVAD management protocol [NUR2016] Routine, Until discontinued, Starting S, Nurse may initiate local CVAD management protocol. Nurse may use local anesthetic for CVAD access per local nursing procedure.
[X] Baseline abdominal girth [NUR428] Routine, Daily, With symptoms of sinusoidal obstruction syndrome (SOS).
[ ] Oxygen therapy [RT83] Routine, Continuous O2 Delivery Method: Nasal cannula Titrate to saturation of: 92% Indications for O2: Hypoxemia Indicate LPM/FiO2: 2 LPM Call provider if oxygen saturation is consistently less than 92% or patient requires increasing oxygen support.
[X] Incentive spirometry nursing [NUR352] Routine, As needed, Every 2 hours while awake.
[X] Daily weights [NUR450] Routine, Daily
[X] Strict intake and output [NUR618] Routine, Every 4 hours, If urine output less than 300 ml every 8 hours, bladder scan and notify provider.
Provider’s Initial:
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[ ] Type of Catheter Panel [408122715] [ X] heparin (porcine) syringe 100 units/mL [123373] 300 Units, IntraVENous, Every 8 hours Heparin (100 units/ml) flush 2.5 ml every 8 hours or PRN after intermittent use.
[ X] sodium chloride 0.9 % (NS) flush syringe [7319] 20 mL, IntraVENous, Every 8 hours 0.9% Sodium Chloride (Normal Saline) flush 20 ml PRIOR to blood draw per nursing policy
[ X] sodium chloride 0.9 % (NS) flush syringe [7319] 10 mL, IntraVENous, Every 8 hours 0.9% Sodium Chloride (Normal Saline) flush 10 ml AFTER each blood draw/infusion followed by Heparin flush when not in use.
Physician Consults [128402]
[ ] Inpatient consult to Infectious Diseases [CON5] ______REQUIRED Reason for Consult? RN/Secretary to contact the consulting provider? Yes
[ ] Inpatient consult to Interventional Radiology [CON45] Reason for Consult?
Ancillary Consults [128400]
[X] Inpatient consult to Care Management [CON583] Home Health needed: DME Needed: Post Acute placement: Other Needs: Reason for Consult?
[ ] PT eval and treat [PT4] Routine, Once For 1 Occurrences Reason for PT? General weakness/deconditioning
[ ] OT eval and treat [OT1] Routine, Once For 1 Occurrences Reason for OT? ADL training(Self-Care training)
[X] Inpatient consult to Dietary [CON34] ______REQUIRED Reason for Consult?
[ ] Inpatient consult to Wound Care/ET [CON506] ______REQUIRED Reason for Consult?
[ ] Nurse to place order for ET nurse if patient develops Routine, Until discontinued, Starting S skin breakdown [NUR185]
Provider’s Initial:
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Labs
Admission Labs [128401]
[X] CBC and differential [LAB293] Once, Starting S For 1 Occurrences
[X] Activated partial thromboplastin time [LAB325] Once, Starting S For 1 Occurrences
[X] Protime-INR [LAB320] Once, Starting S For 1 Occurrences
[X] Thrombin time [LAB324] Once, Starting S For 1 Occurrences
[X] Comprehensive metabolic panel [LAB17] Once, Starting S For 1 Occurrences
[X] Uric acid [LAB141] Once, Starting S For 1 Occurrences
[X] Phosphorus [LAB113] Once, Starting S For 1 Occurrences
[X] Lactate dehydrogenase [LAB96] Once, Starting S For 1 Occurrences
[X] Magnesium [LAB103] Once For 1 Occurrences
[X] Urinalysis with culture, if indicated [LAB3205] Once, Urinalysis with Culture if indicated reflex to Urine Microscopic when: cloudy appearance that does not clear when warming, color other than yellow, pale yellow, or colorless, protein present in any amount, blood present in any amount, positive nitrite, positive WBC screen (leukocyte esterase); also Urine Culture when: positive nitrate, positive yeast, leukocyte esterase >Trace, more than 10 WBC's, or bacteria >10
[ ] hCG, serum, qualitative [LAB144] Once
Daily Labs [129137]
[X] Phosphorus [LAB113] Daily
[X] Magnesium [LAB103] Daily
[X] Comprehensive metabolic panel [LAB17] Every Mon-Wed-Fri
[X] CBC and differential [LAB293] Every Mon-Wed-Fri
Provider’s Initial:
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Microbiology [128407]
[X] MRSA by PCR [LAB1747] Once Place on contact precautions if indicated per MRSA Screen protocol
[X] Initiate Febrile Neutropenia Physician order #895, if Routine, Until discontinued, Starting S temperature is greater than 38 C. Then notify provider. [NUR185]
[ ] Blood culture [LAB462] As needed Repeat culture times 1 every 24 hours for a febrile episode.
[ ] Fungus culture, blood [LAB242] ______REQUIRED As needed Repeat culture times 1 every 24 hours for a febrile episode.
[ ] CMV DNA, quantitative, PCR [LAB913] Weekly
[ ] Aspergillus Galactomannan AG (Serum) [LAB4008] ______REQUIRED Weekly
[ ] VRE culture [LAB238] ______REQUIRED Once For 1 Occurrences
Imaging
Imaging [128405]
[ ] ECG 12 lead [ECG1] ______REQUIRED Routine, Once Reason for Exam (Signs & Symptoms): Reason for Exam (Signs & Symptoms): On admission, if not done in the last 4 weeks.
[ ] ECG 12 lead [ECG1] ______REQUIRED Routine, As needed Reason for Exam (Signs & Symptoms): Reason for Exam (Signs & Symptoms): PRN for recurrent chest pain and notify provider.
[ ] X-ray chest PA or AP [IMG34] ______REQUIRED Routine, 1 time imaging For 1 On admission, if not done in the last 4 weeks. Reason for Exam: Is the patient pregnant? Transport Mode: Transport Mode:
Provider’s Initial:
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[X] X-ray chest PA or AP [IMG34] Routine, 1 time imaging For 1 Occurrences Reason for Exam: Other (Please Specify) Is the patient pregnant? Reason for Exam (USE SIGNS AND SYMPTOMS): Transport Mode: Transport Mode: Bed
[X] Nurse to place CXR order [NUR185] Routine, Until discontinued, Starting S, Nurse to place CXR order weekly for CXR: Reason for exam is Other: BMT Standard of Care
Medications
IV Analgesia [408128272] NOTE: Number those medications desired. The nurse will select #1 as the first medication to be given. If ineffective, #2 will be used next, and then #3, #4, etc. Number IV/IM Meds and Oral Meds separately. If orders chosen are not numbered, the nurse will contact the prescriber for clarification. See Patient controlled Analgesia (PCA) Order#564. No additional IV/IM analgesia while on PCA. Discontinue PCA when tolerating PO pain meds
[ ] morphine injection [420065] ______REQUIRED IntraVENous, Every 1 hour PRN, severe pain Med choice: {Please select from list:40800002} Avoid use in renal dysfunction ( serum creatinine greater than 2 mg/dL or patient on dialysis)
[ ] HYDROmorphone (DILAUDID) injection [420079] 1 mg, IntraVENous, Every 1 hour PRN, severe pain, For 7 Days Med choice: 2 - Second option Note: 1 mg hydromorphone=7mg morphine. Usual starting dose for hydromorphone is 0.2 -0.6 mg in opiate naive patients. Patients with prior opiate exposure may tolerate higher initial dose.
[ ] Pharmacy general consult [CON100] Routine, Once
Oral Analgesia [408128274] NOTE: Number those medications desired. The nurse will select #1 as the first medication to be given. If ineffective, #2 will be used next, and then #3, #4, etc. Number IV/IM Meds and Oral Meds separately. If orders chosen are not numbered, the nurse will contact the prescriber for clarification. See Patient controlled Analgesia (PCA) Order#564. No additional IV/IM analgesia while on PCA. Discontinue PCA when tolerating PO pain meds
[ ] HYDROmorphone (DILAUDID) tablet [40840077] ______REQUIRED 2-4 mg, Oral, Every 3 hours PRN, severe pain Med choice: {Please select from list:40800002}
[ ] oxyCODONE (ROXICODONE) immediate release 5-10 mg, Oral, Every 3 hours PRN, severe pain tablet [40840095] Med choice: 1 - First option
Provider’s Initial: Page 7 of 10 PATIENT INFORMATION Autologous Marrow and Peripheral Blood Stem Cell (PBSC) Admission [30400149]
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Nausea/Vomiting [408128275]
[ ] Pharmacy general consult - Antiemetics [CON100] Routine, Once
[ ] Ondansetron 4 hour PRN Panel [408127358] "Or" Linked Panel
[ ] ondansetron (ZOFRAN) injection 4 mg/2 mL 4 mg, IntraVENous, Every 4 hours PRN, nausea, vomiting [106348] Maximum 24 mg per 24 hours. If ineffective discontinue and give promethazine (Phenergan)
[ ] ondansetron (ZOFRAN-ODT) disintegrating tablet 4 mg, Oral, Every 4 hours PRN, nausea, vomiting [27697] Maximum 24 mg per 24 hours. If ineffective discontinue and give promethazine (Phenergan).
[ ] promethazine (PHENERGAN) 25 mg/mL injection 12.5-25 mg, IntraVENous, Every 4 hours PRN, nausea, [6618] vomiting
[ ] promethazine (PHENERGAN) 25 mg/mL injection 6.25-12.5 mg, IntraVENous, Every 4 hours PRN, nausea, [6618] vomiting Use 6.25-12.5 mg IV for patients age 65 and over
[ ] Lorazapam 6 hour PRN Panel [408128974] "Or" Linked Panel
[ ] LORazepam (ATIVAN) injection 2 mg/mL [10467] 0.5-2 mg, IntraVENous, Every 6 hours PRN, anxiety, Nausea/Vomiting/Anxiety (usual dose 1-2 mg)
[ ] LORazepam (ATIVAN) tablet [40840084] 0.5-2 mg, Oral, Every 6 hours PRN, anxiety, Nausea/Vomiting/Anxiety (usual dose 1-2 mg)
Bowel Program [408128278]
[ ] docusate sodium (COLACE) capsule [2566] 100 mg, Oral, 2 times daily PRN, constipation, Bowel Management Hold for diarrhea
[ ] senna (SENOKOT) tablet 8.6 mg [11349] 1 tablet, Oral, 2 times daily PRN, constipation Hold for diarrhea.
[ ] polyethylene glycol packet 17 gram [25424] 17 g, Oral, 2 times daily PRN, constipation Give in 240 ml of juice or water
Sedative [408128279]
[ ] zolpidem (AMBIEN) tablet [40840003] 5 mg, Oral, Nightly PRN, sleep
Provider’s Initial:
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Prophylaxis [408128280]
[ ] sulfamethoxazole-trimethoprim (BACTRIM DS) tablet ______REQUIRED 800-160 mg [7555] 160 mg of trimethoprim, Oral, 3 times weekly For Pneumocystis jiroceci, if allergic, give Dapsone 50 mg PO daily Please choose an indication
[ ] dapsone tablet [2131] ______REQUIRED 50 mg, Oral, Daily For Pneumocystis jiroceci Please choose an indication . [X] acyclovir (ZOVIRAX) (400mg-800mg) tablet [8971] 800 mg, Oral, 2 times daily If patient HSV positive. If unable to take PO, give 250 mg/m2 IV every 12 hours.
[ ] acyclovir (ZOVIRAX) IVPB in 250 mL for doses > 500 250 mg/m2, IntraVENous, for 60 Minutes, Every 12 hours mg [400282] If patient HSV positive and unable to take PO
[X] levofloxacin (LEVAQUIN) tablet [18918] ______REQUIRED 500 mg, Oral, Daily Begin on transplant day 0 Please choose an indication . [X] fluconazole (DIFLUCAN) tablet [10046] 400 mg, Oral, Daily Begin when ANC is less than or equal to 500
Other Medications [408128281]
[ ] Nurse may initiate OTC Pt Care Products [NUR2066] Routine, Until discontinued, Starting S
[X] sodium chloride irrigation 0.9% [11403] 30 mL, Oral, Every 4 hours Oral rinse every 4 hours and PRN. Initiate Mucositis oncology unit specific nursing protocol #13
[X] sodium chloride irrigation 0.9% [11403] 30 mL, Oral, As needed, Mucositis Oral rinse every 4 hours and PRN. Initiate Mucositis oncology unit specific nursing protocol #13
[ ] nitroglycerin (NITROSTAT) SL tablet [5604] 0.4 mg, SubLINgual, Every 5 min PRN, chest pain, For 4 Doses May repeat times 3 providing systolic blood pressure greater than 90 mmHg. Notify Provider.
Provider’s Initial:
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Nicotine Replacement Therapy [408000001] Nicotine Replacement therapy will be avoided if possible in patient with unstable acute coronary syndrome for 72 hours. After 72 hours if chest pain, arrhythmias, and/or blood pressure have stabilized, Nicotine replacement may be considered at ONE STEP below the calculated replacement dose. NOTE: 1/2 pack = 10 cigarettes
The nicotine products listed below may be used as monotherapy or in combination therapy. Combination therapy should include a nicotine patch plus nicotine gum. Smoking History Recommended Starting Dose
Step down therapy after initial nicotine replacement for 6-7 weeks: Nicotine patch, 7mg
10 Cigarettes per Day or less, past history of cardiovascular disease, or weight under 45 kg: Nicotine patch, 14 mg
Heavy smokers (More than 10 cigarettes/day): Nicotine patch, 21 mg
Smokeless tobacco users, pipe smokers or at patient request: Nicotine Gum, 2mg
Note to provider: Insulin requirements may change - monitor blood sugars. Topical Steroids and oral antihistamines may be recommended to treat less severe skin irritations.
[ ] Patient uses tobacco [206892] [ ] nicotine (NICODERM CQ) 7 mg/24 hr [27860] 1 patch, TransDermal, for 24 Hours, Daily
[ ] nicotine (NICODERM CQ) 14 mg/24 hr [27862] 1 patch, TransDermal, for 24 Hours, Daily
[ ] nicotine (NICODERM CQ) 21 mg/24 hr [27863] 1 patch, TransDermal, for 24 Hours, Daily
[ ] nicotine polacrilex (NICORETTE) gum [10717] 2 mg, Buccal, Every 1 hour PRN, smoking cessation
[ ] buPROPion (WELLBUTRIN SR) 12 hr tablet 100 mg, Oral, 2 times daily [18385] [ ] varenicline (CHANTIX) tablet [76444] 0.5 mg, Oral, 2 times daily with meals
[ ] Patient refuses nicotine replacement medication Details [COR406]
[ ] Patient does not use tobacco [COR405] Details
[ ] Nicotine replacement contraindicated [COR407] ______REQUIRED Reason for contraindication:
DATE TIME ORDERING PROVIDER PRINT NAME
PROVIDER SIGNATURE
DATE TIME RN ACKNOWLEDGED
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