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IP - Rituximab Non-Oncology Infusion - Adult Supplemental

IP - Rituximab Non-Oncology Infusion - Adult Supplemental - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols, Related


IP - Rituximab Non-Oncology Infusion - Adult - Supplemental [1825]
This order set should only be used when ordering rituximab for non-oncologic indications
Intended for Adult Patients Only
Patient Care Orders
Vital Signs [26602]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Obtain prior to infusion, 30 minutes after infusion is started,
and at the completion of infusion, before patient leaves.
Contingency Parameters [26598]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Patient develops signs of an infusion reaction
(flushing, hives, dyspnea, wheezing)
Prescriber Contact Information [128247]
NOTE - If the patient has an acute reaction to the infusion, the infusion will be stopped and treatment for the acute
reaction will be given. The infusion WILL NOT be re-started until you (the original prescriber) or your designee can be
reached to authorize the re-challenge, or provide further instructions. If you cannot be reached, the medication will not be
restarted and the patient will be sent home to follow-up with you, and future doses will not be administered until re-
ordered by you. We will page/call you 3 times in 30 minutes. If we have not received a response from you at the end of 30
minutes, the patient will be discharged.
Notify Provider - Infusion Reaction [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Page 1 of 3
Pr i nt ed by STRAKA, KEVIN F [KFS1] at 8/21/2014 5:00:58 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison


During business hours, I can be reached at this number: ***
After hours, I can be reached at this number: ***
If unable to reach me, please contact the following physician:
*** at this number: ***
Intravenous Therapy
IV Fluids [112009]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Device:
Peripheral IV Location:
Peripheral IV Size:
Peripheral IV Status:
Does this need to be inserted/placed?
Medications - Pre-infusion
Analgesics [27318]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
Antihistamines (Single Response) [27319]
diphenhydramine (BENADRYL) cap [36791] 25 mg, Oral, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
diphenhydramine (BENADRYL) cap [36791] 50 mg, Oral, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
diphenhydramine (BENADRYL) injection [800106] 25 mg, Intravenous, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
diphenhydramine (BENADRYL) injection [800106] 50 mg, Intravenous, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
Steroids (Single Response) [27320]
dexamethasone (DECADRON) intraVENOUS [800037] Intravenous, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
methylprednisolone sodium succ. (SOLU-MEDROL)
intraVENOUS [800058]
100 mg, Intravenous, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
hydrocortisone sod suc in sodium chloride 0.9% injection
[800189]
Intravenous, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
Medications - Infusion
Infusion Agent [27317]
rituximab (RITUXAN) bag [700395] 1,000 mg, Intravenous, ONCE For 1 Doses
Laboratory
Draw Now [26603]
CBC WITH DIFFERENTIAL [CBC] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
FLOW CYTOMETRY, CD 19 AND 20 (A CBC with
Differential Must Be Ordered at Same Time) [HCF1920]
STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine, A WBC and Differential must be ordered at same
time.
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
GGT [GGT] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine
Page 2 of 3
Pr i nt ed by STRAKA, KEVIN F [KFS1] at 8/21/2014 5:00:58 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison


If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
C REACTIVE PROTEIN [CRPN] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR [PT] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
For Patients on Methotrexate [26604]
CBC WITHOUT DIFFERENTIAL [HEMO] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ALBUMIN [ALB] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Page 3 of 3
Pr i nt ed by STRAKA, KEVIN F [KFS1] at 8/21/2014 5:00:58 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison