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WRITE WITH BLACK BALL POINT INK ONLY USING FIRM PRESSURE.
DOCTOR WRITING ORDER IS TO RECORD DATE AND TIME WITH EACH SET OF ORDERS WRITTEN. AUTHENTICATE WITH FULL SIGNATURE AND BEEPER NUMBER.
MR FORM 1C
8/96
PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
Patient’s Weight____________ kg
DIAGNOSIS: _______________________________________________________________________
Hematology/Oncology Hospital Orders
Adult High-Dose Aldesleukin (Proleukin, Interleukin-2, IL-2) Orders
RESPONSIBLE SERVICE/PHYSICIANS: Please notify oncology fellow (pager # 762-2166) of room
number.
CONDITION: G stable
G guarded
G severe
G critical
VITALS: Baseline and Q 4 hours; Pulse oximetry baseline and Q 4 hours
Notify physician systolic B/P less than 90
ACTIVITY: As tolerated
NUTRITION: _______________________________________________________________________
NURSING ORDERS:
Strict I & O; Daily weights
Ensure that CBC, Comprehensive Metabolic Profile, Phos, Mg, and Urinalysis have been done and
results are acceptable values prior to initiating therapy. Ensure that, prior to 1st course of therapy,
Thallium Stress Test, EKG and PFT’s are done and results are acceptable values prior to initiating
therapy.
Heart Monitor
Patient to be placed on monitor while receiving aldesluekin (IL-2) therapy.
DIAGNOSTIC ORDERS:
Daily Labs: CBC with diff, Comprehensive Metabolic Profile, Phos, Mg
MISCELLENOUS ORDERS:
O2 at 2 L via NC prn dyspnea
___________
Initials
Rev. 2/16 JH 2/10/16 Page 1 of 3
Distribution: White - Chart Copy
WRITE WITH BLACK BALL POINT INK ONLY USING FIRM PRESSURE.
DOCTOR WRITING ORDER IS TO RECORD DATE AND TIME WITH EACH SET OF ORDERS WRITTEN. AUTHENTICATE WITH FULL SIGNATURE AND BEEPER NUMBER.
MR FORM 1C
8/96
PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
Hematology/Oncology Hospital Orders
Adult High-Dose Aldesleukin (Proleukin, Interleukin-2, IL-2) Orders
New medication for this admission:
IVF: NS 1L with 20 mEq KCl at 50 mL/hr OR ________________________________________________________ mL/hr
(type of fluid)
1. Diphenhydramine 25 mg PO every 4 hours prn pruritis
2. Meperidine 25 mg IV every hour for rigors
3. Lorazepam 1 mg PO every 8 hours prn anxiety
4. Lorazepam 1 mg PO QHS prn insomnia
5. Prochloroperazine 10 mg PO every 4 hours prn nausea
6. Promethazine 25 mg IV every 6 hours prn vomiting
7. Loperamide 4 mg PO after initial loose stool followed by 2 mg after each loose stool (max 16 mg/day)
8. Pantoprazole 40 mg PO every AM
9. Moisturizing lotion prn to affected skin
Aldesleukin (IL-2) Scheduled Pre-medications:
1. Acetaminophen 650 mg PO 30 minutes prior to first IL-2 dose, followed by every 4 hours scheduled until 12 hours
after final dose of IL-2. If unable to take PO, may give acetaminophen 650 mg PR every 4 hours until 12 hours after
last IL-2 dose.
2. Ibuprofen 200 mg PO every 4 hours prn fever not relieved by acetaminophen; hold if serum creatinine doubles from
baseline or if serum creatinine 1.5 mg/dL or greater
3. Granisetron 1 mg IVP every 24 hours starting before the first IL-2 dose; DC on the day of final IL-2 dose
Aldesleukin (IL-2): 600,000 units/kg/dose = _______________ units/dose in 50 mL D5W. Give IV over 15 minutes every
8 hours (administer at 0800, 1600, and 2400 hours). Give no more than 14 doses. Piggyback in to D5W flush bag only;
flush before and after each dose before resuming IVF – incompatible with NS
Patient should NOT receive steroids (systemic or topical) during IL-2 therapy
Hold scheduled dose of IL-2 if 1-3 relative criteria have been met and notify physician. Once corrective measures have
been taken and physician has determined therapy can continue, administer the next dose of IL-2 at the next scheduled time
(0800, 1600, or 2400 hours).
Permanently discontinue IL-2 if 4 or more relative criteria or if any absolute criteria have been met and notify physician.
Permanently discontinue IL-2 if patient does not receive two consecutive IL-doses due to toxicities. Notify physician.
_________________________________ __________________ ______________________________________________ _________________________
Staff Physician Name (Print)
Pager
Staff Physician Signature
Date/Time
G Pregnancy test negative or N/A
_________________________________ __________________ ______________________________________________ _________________________
Fellow (Print)
Pager
Fellow signature
Date/Time
_________________________________ __________________ ______________________________________________ _________________________
Oncology RN/CNS or PharmD (Print) Pager Oncology RN/CNS or PharmD signature
Rev. 2/16 JH 2/10/16 Page 2 of 3
Distribution: White - Chart Copy
Date/Time
WRITE WITH BLACK BALL POINT INK ONLY USING FIRM PRESSURE.
DOCTOR WRITING ORDER IS TO RECORD DATE AND TIME WITH EACH SET OF ORDERS WRITTEN. AUTHENTICATE WITH FULL SIGNATURE AND BEEPER NUMBER.
MR FORM 1C
8/96
PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
Hematology/Oncology Hospital Orders
Adult High-Dose Aldesleukin (Proleukin, Interleukin-2, IL-2) Orders
System
Cardiac
Relative Criteria
Absolute Criteria
Sinus tachycardia 120-130 bpm
SBP less than 90 mmHg
Sinus tachycardia greater than 130 bpm
EKG changes consistent with ischemia
Atrial fibrillation
Supraventricular tachycardia
Ventricular arrhythmias
Elevated CPK-MB
Dermatologic
Moist desquamation
Gastrointestinal
Diarrhea 1 L or more in 8 hours
Ileus
Abdominal distention
Diarrhea 1 L or more in 8 hours x 2
Vomiting unresponsive to medication
Severe abdominal distension affecting breathing
Severe abdominal pain
Hemodynamic
Max. phenylephrine 1-1.5 mcg/kg/min
Min. phenylephrine greater than 0.5 mcg/kg/min
Max. phenylephrine 1.5-2 mcg/kg/min
Min. phenylephrine greater than 0.8 mcg/kg/min
Hemorrhagic
Guaiac + sputum, emesis, or stool
Platelets less than 50,000/mm3
Frank blood in sputum, emesis, or stool
Platelets less than 30,000/mm3
Infectious
Documented infection or strong clinical suspicion
of infection
Neurologic
Vivid dreams
Emotional lability
Pulmonary
Resting SOB; 3-4 L O2 via NC for sat greater greater than 4 L O2 via NC for sat greater than 95%
than 95%
40% O2 via mask for sat greater than 95%
Rales 1/3 up chest
Endotracheal intubation
Rales 1/2 up chest
Pleural effusion requiring tap or chest tube during
therapy
Renal
Urine 80-160 mL/8 hours
Urine 10-20 mL/hour
Creatinine 2.5-2.9 mg/dL
Weight Gain
15% or greater weight gain over baseline
weight
_________/_________/_________
Date
_________________________________
Physician Last Name (Print)
Mental status changes not reversible in 2 hours
Disorientation
Hallucinations
Urine less than 80 mL/8 hours
Urine less than 10 mL/hour
Creatinine 3 mg/dL or greater
_____________________
Time
____________________
Pager
__________________________________________
Physician Signature
Rev. 2/16 JH 2/10/16 Page 3 of 3
Distribution: White - Chart Copy