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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98237-en.cckm

201608214

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UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

IP - Rituximab Non-Oncology Infusion - Adult - Supplemental [1825]

IP - Rituximab Non-Oncology Infusion - Adult - Supplemental [1825] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


SmartSet: IP - RITUXIMAB NON-ONCOLOGY INFUSION DELEGATION
PROTOCOL - ADULT - SUPPLEMENTAL (ID:1825)
General Information
Display name: IP - Rituximab Non-Oncology Infusion Delegation Protocol - Adult - Supplemental
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. RITUXAN
2. RITUXIMAB
3. .OTHER
4. .SUPPLEMENTAL
SmartSet notes:
Description: This order set should only be used when ordering rituximab for non-oncologic
indications
Intended for Adult Patients Only
Web information: Title URL
1.
Questionnaire:
Configuration
Patient Care Orders
Vital Signs
Vital Signs SEE COMMENTS, Starting S, 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
Page 1 of 4
Printed by STRAKA, KEVIN F [KFS1] at 8/1/2016 1:28:26 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Notify Provider 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),Heart rate
changes by plus or minus 20 beats/minute from
baseline,Blood pressure changes by plus or minus 20
mmHg from baseline
Prescriber Contact Information
Notify Provider - Infusion Reaction Provider to Notify: Provider
Notify based on:
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
Insert and Maintain Peripheral IV CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Medications - Pre-infusion
Analgesics
acetaMINOPHEN (TYLENOL) tab 650 mg, Oral, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
Antihistamines
diphenhydramine (BENADRYL) cap 25 mg, Oral, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
diphenhydramine (BENADRYL) cap 50 mg, Oral, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
diphenhydramine (BENADRYL) injection 25 mg, Intravenous, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
Page 2 of 4
Printed by STRAKA, KEVIN F [KFS1] at 8/1/2016 1:28:26 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg, Intravenous, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
Steroids
dexamethasone (DECADRON) intraVENOUS Intravenous, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
methylprednisolone sodium succ. (SOLU-
MEDROL) intraVENOUS
100 mg, Intravenous, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
hydrocortisone sod suc in sodium chloride 0.9%
injection
Intravenous, ONCE For 1 Doses
Administer 30 minutes prior to rituximab
Medications - Infusion
Infusion Agent
rituximab (RITUXAN) bag 1,000 mg, Intravenous, ONCE For 1 Doses
Laboratory
Draw Now
CBC WITH DIFFERENTIAL STAT - RN COLLECT, Starting S 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)
STAT - RN COLLECT, Starting S 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 STAT - RN COLLECT, Starting S 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 STAT - RN COLLECT, Starting S For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
C REACTIVE PROTEIN STAT - RN COLLECT, Starting S 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 STAT - RN COLLECT, Starting S 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 4
Printed by STRAKA, KEVIN F [KFS1] at 8/1/2016 1:28:26 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

BILIRUBIN, TOTAL STAT - RN COLLECT, Starting S 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
CBC WITHOUT DIFFERENTIAL STAT - RN COLLECT, Starting S 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 STAT - RN COLLECT, Starting S 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 STAT - RN COLLECT, Starting S For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Criteria
Suggestions:
Filter: UWIP ORDER SET RESTRICTION - HOSPITAL ENCOUNTERS EXCEPT ED -
NOT IP DC[3000400]
Restrict SmartSet:
Settings
Discontinue action:
Deselect sections for
Pended/Held orders:
Pended/Held orders
display:
Release date: Use System Definitions Setting
Disallow user override:
Page 4 of 4
Printed by STRAKA, KEVIN F [KFS1] at 8/1/2016 1:28:26 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org