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BIDMC Provider Order Entry - Order Sets General Design Order sets are a list of suggested orders for a particular patient event (e.g. admit) or disease condition (heart failure). Most order sets fit one of the two basic templates listed below and are not designed as custom screens but run through a central screen driver. Each order on a set must be orderable as an individual order via the main POE system, although some parameters may be left blank on the set. The end user must click each order on a set to order it; there is no signoff on a group of orders with one click. When clicked on from the set, orders may branch to the main POE order screen with parameters from the set pre-filled. The user can add/edit/confirm data and also may see warnings that are specific to the patient/time of order. This design (reuse of main ordering screens) helps keep the order sets from falling out of sync with the evolving POE system. Basic Templates Procedure, Miscellaneous o One time orders around a particular event that add to existing active order profile for the patient o Sequence of orders specific to each set Admit, Transfer, Postoperative o Complete set of orders that will become the active order profile when signed o Sequence of order categories is defined but some categories may be omitted Service based (Cardiac Surgery, Psychiatry, OB/GYN etc) Diagnosis/Procedure based (Heart Failure, Sepsis, Kidney Transplant, BMT, etc) Page 1 of 59 Procedure/Miscellaneous Sets Page 2 of 59 Procedure/Miscellaneous Sets Page 3 of 59 Procedure/Miscellaneous Sets Page 4 of 59 Procedure/Miscellaneous Sets Page 5 of 59 Procedure/Miscellaneous Sets Page 6 of 59 Procedure/Miscellaneous Sets Page 7 of 59 Procedure/Miscellaneous Sets Page 8 of 59 Procedure/Miscellaneous Sets Page 9 of 59 Procedure/Miscellaneous Sets Page 10 of 59 Procedure/Miscellaneous Sets Page 11 of 59 Procedure/Miscellaneous Sets Page 12 of 59 Procedure/Miscellaneous Sets Page 13 of 59 Procedure/Miscellaneous Sets Page 14 of 59 Procedure/Miscellaneous Sets Page 15 of 59 Procedure/Miscellaneous Sets Page 16 of 59 Admit/Transfer/Postoperative Sets Heart Failure Heart Failure (cont) Page 17 of 59 Admit/Transfer/Postoperative Sets Popup for ARB meds: Page 18 of 59 Admit/Transfer/Postoperative Sets Heart Failure (cont) Sample Med Pop-up Screen Page 19 of 59 Admit/Transfer/Postoperative Sets Sample weight-based heparin order screen Sepsis Page 20 of 59 Admit/Transfer/Postoperative Sets Page 21 of 59 Admit/Transfer/Postoperative Sets Cardiac Medicine Interventional Service Admission Page 22 of 59 Admit/Transfer/Postoperative Sets Psychiatry Admission Page 23 of 59 Admit/Transfer/Postoperative Sets Whipple Resection Postop Orders Allergies Edit Delete Postop orders: Admit to Surgery - Gold; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: per routine I & O: Yes click to Incentive spirometry: 10x per hr Order Call HO if: T>101.5 ; HR <60 or >110 ; SBP <80 or >160 ; DBP <60 or >90 ; RR <10 or >24 ; U/O <20 cc/hr ; GLU <80 or >500 ; O2 <91% ; click to o2 Sats: AM POD 1 and POD 2 Order Activity click to Order Bedrest tonight. OOB to chair POD 1. Ambulate starting POD 2. Tubes/Drains click to Closed suction drain Order Reconstitute and Record q Shift click to NGT low continuous suction Order Flush q shift with 10 cc NS click to Foley to gravity Order Oxygen Therapy click to Oxygen Therapy: Nasal cannula 4 L/min D/C when sats > 91% by pulse oximetry Order Nutrition click to Order click to Order Diet: NPO Nutrition consult: Postop Whipple Resection General Xray click to Portable CXR to be done in PACU Order Radiology General Xray Other click to Order click to Order click to Order click to Accucheck on arrival to PACU - then QID Thigh-high TED hose on at all times Calf pneumatic boots on while in bed. D/C when ambulating. Pain control via Epidural or PCA as per APS. Page 24 of 59 Admit/Transfer/Postoperative Sets Order click to Order IV access click to Order Social Work consult for discharge planning on POD 1. IV access: Central Line IV fluids click to Order Medication click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order Lab click to Order click to Order click to Order 1000 ml D5 1/2NS Continuous at 125 ml/hr for 24 hrs postop. Then run at 75 ml/hr until D/C'd. Med Order Set Insulin Pantoprazole 40 mg IV Q24H Heparin 5000 UNIT SC Q12H If necessary Octreotide Acetate 100 mcg SC Q8H Acetaminophen 650 mg PO Q4-6H:PRN Diphenhydramine HCl 25 mg PO/IV HS:PRN Metoclopramide 10 mg PO QID Start: POD 5 Dolasetron Mesylate 12.5 mg IV Q8H:PRN Blood, To be collected , in PACU: CBC; Sodium; Potassium; Chloride; Bicarbonate; Glucose; BUN; PT; Creatinine Blood, To be collected , IN AM POD 1: CBC; Sodium; Potassium; Chloride; Bicarbonate; Glucose; BUN; PT; Creatinine Blood, To be collected , IN AM POD 4: CBC; Sodium; Potassium; Chloride; Bicarbonate; Glucose; BUN; Creatinine Done Page 25 of 59 Admit/Transfer/Postoperative Sets Laparoscopic Gastric Bypass Orders Allergies Edit Delete Postop orders: Admit to Surgery - Purple; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: per routine click to o2 Sats: with vitals Order I & O: Yes Incentive spirometry: 10x per hr Activity click to Order click to Order Pneumatic boots Activity: Ambulate tid Wound Care Therapeutic devices/DVT/Prophylaxis Tubes/Drains click to Foley to gravity Order click to G-tube to gravity Order click to NGT low continuous suction Order click to Other Order JP drain to bulb suction Nutrition click to Order Diet: NPO General Xray click to UGIS/SBFT in AM Order Radiology General Xray Other click to Order click to Order Patient has a gallbladder. Patient does not have a gallbladder. IV access IV fluids click to Order 1000 ml LR Continuous at 200 ml/hr Page 26 of 59 Admit/Transfer/Postoperative Sets Medication click to Order click to Order click to Order click to Order click to Order click to Order click to Order Lab click to Order click to Order Med Order Set Cefazolin 2 gm IV Q8H Duration: 24 Hours Heparin 5000 UNIT SC Q8H Famotidine 20 mg IV Q12H Morphine Sulfate 1 mg IVPCA Lockout Interval: 6 minutes Basal Rate: 0 mg(s)/hour 1hr Max Limit: 10 mg(s) Methylene Blue 1% 3 ml PO ONCE Duration: 1 Doses Start: @1800 on POD 0 Please dilute 3 ml in 27 ml water (30 ml total). Check JP output 1 hour later & contact HO ASAP if any blue is present. Prochlorperazine 10 mg IV Q6H:PRN nausea Dolasetron Mesylate 12.5 mg IV ONCE for nausea not responsive to compazine Duration: 1 Doses Blood, To be collected NEXT ROUNDS: Hematocrit Blood, To be collected MORNING OF : Hematocrit Done Page 27 of 59 Admit/Transfer/Postoperative Sets Transplant Service Hepatobiliary Post-op Orders Kidney Transplant Post-op Orders Orthotopic Liver Transplant Post-op Orders Pancreas and Simultaneous Kidney/Pancreas Transplant Post-op Order Page 28 of 59 Admit/Transfer/Postoperative Sets Hepatobiliary Post-op Orders Allergies Edit Delete Postop orders: Admit to Surgery - Blue; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: per routine I & O: Yes Monitor urine output: q2h click to Incentive spirometry: q2h while awake; turn side to side and cough q2h Order Call HO if: T>100.5 ; HR <60 or >110 ; SBP <100 or >160 ; DBP <50 or >100 ; RR <10 or >22 ; U/O <50 /hr ; O2 <93 ; Post-procedure vitals: q 1 hr for 2 hrs; q 2 hrs for 8 hrs; then: q4h Activity click to Order Activity: Out of bed to chair qid Ambulate qid with assistance until independent Wound Care click to Order click to Order Wound care: Site: Incision Type: Surgical Wound care: Site: drain site Change dressing: qd Therapeutic devices/DVT/Prophylaxis Tubes/Drains click to Foley to gravity Order Tape foley to anterior thigh click to NGT low continuous suction Order Irrigate w/ 10-20 ml normal saline PRN. Empty and record output q4h. click to T tube Order to gravity drain. Empty and record output q2h. Closed suction drain bulb suction click to strip q1-2h and PRN. Empty and record output q2h and PRN if necessary to maintain Order adequate suction. Oxygen Therapy click to Oxygen Therapy: Nasal cannula Order Nutrition Other IV access click to Order IV access: Central Line Page 29 of 59 Admit/Transfer/Postoperative Sets click to Order IV fluids click to Order Medication click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order IV access: Peripheral saline lock 20 mEq KCL / 1000 mL D5 1/2NS Continuous Med Order Set Unasyn 3 gm IV Q6H Morphine Sulfate 2-6 mg IV Q4H:PRN pain Promethazine HCl 12.5 mg IV Q6H:PRN nausea Promethazine HCl 12.5-25 mg PO Q6H:PRN nausea Acetaminophen 325-650 mg PO/PR Q4-6H:PRN Temp above 101F Heparin 5000 UNIT SC Q8H Famotidine (IV) 20 mg IV Q12H Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea Lab Done Page 30 of 59 Admit/Transfer/Postoperative Sets Kidney Transplant Post-op Orders Allergies Edit Delete Flomax Postop orders: Admit to Surgery - Transplant; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: per routine Weight: qd I & O: Yes click to Monitor urine output: q1h Order Incentive spirometry: with teaching Call HO if: HR <50 or >120 ; SBP <110 or >190 ; DBP <60 or >90 ; RR <10 or >22 ; U/O <1 ml/kg/hr ; GLU <70 or >200 ; O2 <93 ; Post-procedure vitals: q 15 min for 1 hrs; q 30 min for 2 hrs; q 1 hr for 4 hrs; then: q2h Activity click to Order Activity: Out of bed to chair Pneumatic boots Tubes/Drains click to Closed suction drain JP drains bulb suction Order Empty and record PRN. click to Foley to gravity Order Nutrition click to Order Diet: Clear liquids Central TPN General Xray click to Chest PORTABLE AP; schedule as STAT Order Radiology General Xray IV access click to Order IV access: Central Line IV fluids click to Order click to Order Medication click to 1000 ml D5 1/2NS Continuous, Replacement Fluid: ml/ml replacement of urine output, not less than 50 ml/hr 1000 ml 1/2NS Continuous, Replacement Fluid: ml/ml replacement of urine output, not less than 50 ml/hr Med Order Set Pamidronate 30 mg IV ONCE Duration: 1 Doses Start: POD #1 Page 31 of 59 Admit/Transfer/Postoperative Sets Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order Lab click to Order click to Order Sulfameth/Trimethoprim SS 1 TAB PO DAILY * Drug-Allergy Warning * Valganciclovir HCl 450 mg PO DAILY Pantoprazole 40 mg PO Q24H Start: When patient taking PO Nystatin Oral Susp. 5 ml PO BID Start: When tolerating PO Docusate Sodium 100 mg PO BID Morphine Sulfate 1 mg IVPCA Lockout Interval: 15 minutes Basal Rate: 0 mg(s)/hour 1hr Max Limit: 4 mg(s) Acetaminophen 650 mg PO Q6H:PRN Diphenhydramine HCl 25-50 mg PO Q12H OR QHS PRN sleep Heparin 5000 UNIT SC Q8H Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea Blood, To be collected NEXT ROUNDS: CBC; Sodium; Potassium; Chloride; Bicarbonate; Plt Count; Glucose; BUN; Creatinine; Phosphate; Magnesium Blood, To be collected MORNING OF : CBC; Sodium; Potassium; Chloride; Bicarbonate; Plt Count; Glucose; BUN; Creatinine; Phosphate; Magnesium; Cyclosporin; Tacrolimus Done Page 32 of 59 Admit/Transfer/Postoperative Sets Orthotopic Liver Transplant Post-op Orders Allergies Edit Delete Postop orders: Admit to Surgery - Transplant; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: per routine Weight: qd I & O: Yes Monitor urine output: q1h click to Order Incentive spirometry: TCDB and incentive spirometer q2h after extubation, while awake Call HO if: T>100.5 ; HR <60 or >120 ; SBP <100 or >180 ; DBP <50 or >100 ; RR <10 or >22 ; O2 <93 ; Post-procedure vitals: q 15 min for 1/2 hr; q 30 min for 4 hrs; then: q1h Hemodynamic monitoring PA line: in place, transduce Wedge: q4h Hemodynamic profile (CO,CI,SVR,PVR): click to Order q4h Cardiac output method: Thermodilution Flush w/: heparinized saline Other instructions CVP, PAP q1h A line: in place,transduce Flush w/: heparinized saline Other instructions continuous click to Order SVO2 monitoring click to Order CVL: tranduce CVP Other instructions Call HO for CVP > or CVP < Activity click to Order Activity: Bedrest with bed position Head of bed <30 Pneumatic boots Wound Care Wound care: Site: JP and T-tube click to Order Dressing: Gauze - dry Comment: Change dressing QD and PRN Wound care: Site: Incision click to Order Type: Surgical Dressing: Gauze - dry Comment: Change dressing prn Tubes/Drains click to Order click to Order click to Order click to Order Foley to gravity Do not irrigate unless plugged NGT low continuous suction Output q4h T tube to gravity, output q1h Closed suction drain Strip tubing q1-2h and PRN; Output q1h and PRN to maintain adequate suction; Page 33 of 59 Admit/Transfer/Postoperative Sets Clean connection with betadine before opening and closing Mechanical Ventilation Nutrition click to Order Diet: NPO Central TPN General Xray click to Order Chest Portable AP, schedule as STAT Radiology General Xray Other click to Order IV access click to Order If temp greater than 38 deg C (100.5F) orally, obtain blood cultures for aerobes, anaerobes and fungus if not sent in the last 24 hours. Check with MD whether sputum, urine and drain cultures are required. IV access: Central Line IV fluids 1000 ml D5 1/2NS Continuous at 125 ml/hr Medication Med Order Set click to Order Valganciclovir HCl 450 mg PO DAILY click to Order Famotidine (IV) 20 mg IV Q12H click to Order Fluconazole 400 mg PO/NG Q24H For Serum creatinine <3 mg/dL click to Order Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY * Drug-Allergy Warning * For Serum creatinine >3 mg/dL click to Order Sulfameth/Trimethoprim DS 0.5 TAB PO DAILY * Drug-Allergy Warning * click to Order Morphine Sulfate 2 mg IV Q1-2H:PRN click to Order Heparin 5000 UNIT SC Q8H click to Order Unasyn 1.5 gm IV Q6H Duration: 8 Doses click to Order Lab click to Order click to Order click to Order click to Order click to Order click to Order Blood Gases - Arterial, To be collected 03/10/03, on admission to SICU and q8h x 24hrs, process STAT: ABG (1 of 4) Blood Gases - Arterial, To be collected , second draw, process STAT: ABG (2 of 4) Blood Gases - Arterial, To be collected , third draw, process STAT: ABG (3 of 4) Blood Gases - Arterial, To be collected , fourth draw, process STAT: ABG (4 of 4) Blood, To be collected , on admission to SICU: CBC; Sodium; ALT; Potassium; AST; Chloride; Alk Phos; Bicarbonate; Total Bili; Glucose; BUN; PT; Creatinine; Amylase; PTT; Calcium; Phosphate; Fibrinogen; Magnesium; Bilirubin, Direct Blood, To be collected , 8 hrs after SICU admission labs: CBC; Sodium; ALT; Potassium; AST; Chloride; Alk Phos; Bicarbonate; Total Bili; Glucose; BUN; PT; Creatinine; PTT; Fibrinogen; Bilirubin, Direct Page 34 of 59 Admit/Transfer/Postoperative Sets click to Order Blood, To be collected , 8 hrs after 2nd draw: CBC; Sodium; ALT; Potassium; AST; Chloride; Alk Phos; Bicarbonate; Total Bili; Glucose; BUN; PT; Creatinine; PTT; Fibrinogen; Bilirubin, Direct Page 35 of 59 Admit/Transfer/Postoperative Sets Pancreas and Simultaneous Kidney/Pancreas and Transplant Post-op Orders Allergies Edit Delete Postop orders: Admit to Surgery - Transplant; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: per routine o2 Sats: continuous Weight: qd click to I & O: Yes Order Fingerstick: q 1hr X4, then q 2hrs while in SICU Call HO if: HR <50 or >120 ; SBP <110 or >190 ; GLU <70 or >200 ; O2 <93 ; CVP <4 or >20; HCT <24 ; Hemodynamic monitoring click to CVL: tranduce CVP Order Activity click to Order Activity: Out of bed to chair Tubes/Drains click to Foley to gravity Order click to NGT low continuous suction Order Absolutely nothing per NG tube click to Closed suction drain bulb suction Order empty and record PRN Nutrition click to Order Diet: NPO Absolutely nothing by mouth Central TPN General Xray click to Chest Portable AP; schedule as STAT Order Radiology General Xray IV access IV fluids click to Order click to Order 1000 ml D5 1/2NS Continuous, Replacement Fluid: ml/ml of urine output, not less than 125 ml/hr Simultaneous kidney/pancreas transplant 1000 ml D5 1/2NS Continuous at 50 ml/hr Pancreas transplant Page 36 of 59 Admit/Transfer/Postoperative Sets Medication click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order Lab click to Order click to Order click to Order click to Order Med Order Set Pamidronate 30 mg IV ONCE Duration: 1 Doses Start: POD #1 Heparin IV Start: 4 - 6 hrs post-operatively No Initial Bolus Initial Infusion Rate: 200 units/hr Unasyn 3 gm IV Q8H Duration: 6 Doses Fluconazole 400 mg IV Q24H Valganciclovir HCl 450 mg PO DAILY Start: POD #5 Famotidine (IV) 20 mg IV Q12H until tolerating PO, then DC Pantoprazole 40 mg PO Q24H Start: when tolerating PO Octreotide Acetate 100 mcg SC Q8H Blood, To be collected , on arrival to SICU: CBC; Sodium; Potassium; Chloride; Hematocrit; Bicarbonate; Plt Count; Glucose; BUN; Creatinine; Amylase; Lipase Blood, To be collected , 6 hrs after first draw: Hematocrit Blood, To be collected , 12 hrs after first draw : CBC; Sodium; Potassium; Chloride; Hematocrit; Bicarbonate; Plt Count; BUN; Creatinine; Amylase; Lipase Blood, To be collected , 18 hrs after first draw: Hematocrit Done Page 37 of 59 Admit/Transfer/Postoperative Sets Labor and Delivery Orders Allergies Edit Delete Admit to Obstetrics - L & D; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: BP, HR: q2h; Temp q4h click to I & O: Yes Order Call HO if: T>100.4 ; HR <60 or >130 ; SBP <90 or >160 ; DBP <60 or >90 ; RR <10 or >22 ; U/O <30 cc/hr ; O2 <93% RA ; click to Vital signs: per Preeclampsia Magnesium Protocol Order click to Vital signs: per Preterm Magnesium Protocol Order OB click to Order Activity click to Order Nutrition click to Order click to Order Other click to Order IV access click to Order OB Fetal monitoring Activity: Activity as tolerated Diet: Clear liquids, low fat 40 gm until active labor established Diet: NPO , may take ice chips Foley to gravity. IV access: Peripheral IV fluids click to Order Medication click to Order click to Order click to Order click to 1000 ml LR Continuous at 125 ml/hr Adjust rate as needed Med Order Set Penicillin G Potassium 4 MU IV ONCE Duration: 1 Doses LOADING DOSE Penicillin G Potassium 2 MU IV Q4H Clindamycin 600 mg IV Q8H Ampicillin 2 gm IV Q6H Page 38 of 59 Admit/Transfer/Postoperative Sets Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order Lab click to Order click to Order click to Order Gentamicin 120 mg IV ONCE Duration: 1 Doses LOADING DOSE Gentamicin 80 mg IV Q8H Misoprostol 25 mcg VG Q4-6H:PRN Duration: 3 Doses For induction of labor as per protocol. Magnesium Sulfate (L&D) 4 gm IV BOLUS ONCE Duration: 1 Doses Bolus: 4 gm over 20 minutes Magnesium Sulfate (L&D) 2 gm/hr IV DRIP INFUSION Start: After completion of bolus dose Terbutaline Sulfate 0.25 mg SC MR Q20MIN X3 Hold for MHR>120 Terbutaline Sulfate 5 mg PO TID Hold for MHR>120 Hydralazine HCl 5 mg IV ONCE Duration: 1 Doses Methylergonovine Maleate 0.2 mg IM ONCE Duration: 1 Doses Nalbuphine HCl 10 mg IM ONCE Duration: 1 Doses Nalbuphine HCl 10 mg IV ONCE Duration: 1 Doses IV dose must follow IM dose Oxytocin 2 MILLI UNITS/MIN IV DRIP INFUSION Increase by ___ mu/min every ___ min until contractions are q2-3min apart or to a maximum of ___ mu/min. Discontinue for hyperstimulation and/or a non-reassuring FHR pattern. Betamethasone Sodium Phos/Acet 12 mg IM Q24H Duration: 2 Doses Erythromycin 250 mg PO Q6H Duration: 7 Days Labetalol HCl 100 mg PO BID Hold for Maternal SBP <100 and/or MHR <50 Labetalol HCl 10 mg IV ONCE Duration: 1 Doses Hold for Maternal SBP <100 and/or MHR <50 Dexamethasone 6 mg IM Q12H Duration: 4 Doses Sodium Citrate 30 ml PO ONCE:PRN epidural or c-section Administer within 15 minutes of procedure Blood, To be collected STAT: CBC Urine, To be collected STAT: UA dipstick only LABS for patients with preeclampsia Blood, To be collected STAT: CBC; ALT; Plt Count; Creatinine; Uric Acid Blood tests Page 39 of 59 Admit/Transfer/Postoperative Sets Antepartum Orders Allergies Edit Delete Admit to Obstetrics - Antepartum; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: BP, T, P, R qshift click to Weight: weekly Order Call HO if: T>100.4 ; HR <60 or >130 ; SBP <90 or >160 ; DBP <60 or >90 ; RR <10 or >22 ; U/O <30 cc/hr ; O2 <93% RA ; click to Fingerstick: 2 hrs after every meal Order click to DTR/Clonus: q4 Order click to Vital signs: per Preeclampsia Magnesium Protocol Order click to Vital signs: per Preterm Magnesium Protocol Order OB click to Order click to Order click to Order click to Order Activity click to Order click to Order Nutrition click to Order click to Order Consults click to Order Other click to OB Fetal monitoring OB ATU Check FHR Qshift; Check Active Fetal Movement Qshift; Activity: Activity as tolerated Activity: Bedrest with bathroom privileges Nutrition consult: Initial patient assessment Diet: House diet Consults Physical Therapy NICU Consult - MD must call to arrange. Page 40 of 59 Admit/Transfer/Postoperative Sets Order click to Order click to Order UA dipstick only Q Tuesday. Joslin Consult. MD must call to arrange. IV access IV fluids Medication click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order Lab click to Order Med Order Set Docusate Sodium 100 mg PO BID:PRN Acetaminophen 650 mg PO Q6H:PRN Oxazepam 15-30 mg PO HS:PRN insomnia Calcium Carbonate 500 mg PO QID:PRN Milk of Magnesia 15-30 ml PO Q6H:PRN Nephrocaps 1 CAP PO DAILY Clindamycin 600 mg IV Q8H Ampicillin 2 gm IV Q6H Gentamicin 120 mg IV ONCE Duration: 1 Doses LOADING DOSE Gentamicin 80 mg IV Q8H Magnesium Sulfate (L&D) 4 gm IV BOLUS ONCE Duration: 1 Doses Bolus: 4 gm over 20 minutes Magnesium Sulfate (L&D) 2 gm/hr IV DRIP INFUSION Start: After completion of bolus dose Hydralazine HCl 5 mg IV ONCE Duration: 1 Doses Methylergonovine Maleate 0.2 mg IM ONCE Duration: 1 Doses Erythromycin 250 mg PO Q6H Duration: 7 Days Labetalol HCl 100 mg PO BID Hold for Maternal SBP <100 and/or MHR <50 Labetalol HCl 10 mg IV ONCE Duration: 1 Doses Hold for Maternal SBP <100 and/or MHR <50 Bisacodyl 10 mg PR DAILY:PRN Blood, To be collected NEXT ROUNDS: CBC; ALT; Creatinine; Uric Acid Page 41 of 59 Admit/Transfer/Postoperative Sets click to Order Urine, To be collected ROUTINE: Protein, total; Creatinine Blood tests Done Page 42 of 59 Admit/Transfer/Postoperative Sets ] Postpartum Orders Allergies Edit Delete Transfer to Obstetrics - Postpartum; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: BP, T, P, R qshift click to Call HO if: T>100.4 ; HR <60 or >130 ; SBP <90 or >160 ; DBP <60 or >90 ; RR <10 Order or >22 ; U/O <30 cc/hr ; O2 <93% RA ; OB Activity click to Order Nutrition click to Order Other click to Order click to Order click to Order click to Order click to Order click to Order Activity: Ambulate Diet: House diet RhoGAM if indicated. D/C IV fluids when tolerating adequate POs. D/C Foley in 12-24 hours if u/o >30 cc per hour Ice to perineum first 12-24hours prn. Sitz baths prn. May shower. Heating pad prn. If unable to void, follow protocol for management of postpartum bladder distention. If patient on WIC, obtain HCT first postpartum day. IV access IV fluids Medication click to Order click to Order click to Order click to Order click to Order Med Order Set Docusate Sodium 100 mg PO BID:PRN Oxycodone-Acetaminophen 1-2 TAB PO Q4-6H:PRN Ibuprofen 600 mg PO Q6H:PRN Codeine Sulfate 30-60 mg PO Q4-6H:PRN Acetaminophen 500-1000 mg PO Q4-6H:PRN Page 43 of 59 Admit/Transfer/Postoperative Sets click to Order click to Order click to Order click to Order click to Order Lab click to Order Bisacodyl 10 mg PR DAILY:PRN Milk of Magnesia 30 ml PO HS:PRN Dibucaine 1 Appl TP PRN to perineum Simethicone 80 mg PO QID:PRN Calcium Carbonate 500 mg PO QID:PRN LABS for patients with preeclampsia Blood, To be collected , routine: CBC; ALT; Plt Count; Creatinine; Uric Acid Blood tests Done Page 44 of 59 Admit/Transfer/Postoperative Sets GYN Postop Orders Allergies Edit Delete Postop orders: Admit to GYN; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: q4 click to o2 Sats: with vitals Order Incentive spirometry: 10x per hr Call HO if: T>100.4 ; U/O <30cc x 2h ; Activity click to Order Activity: Ambulate tid Pneumatic boots Wound Care Tubes/Drains click to Foley to gravity Order DC in am Nutrition click to Order Other click to Order IV access click to Order Diet: House diet Advance diet as tolerated RhoGAM if indicated. IV access: Peripheral IV fluids click to Order Medication click to Order click to Order click to Order click to Order click to Order 1000 ml LR Continuous at 125 ml/hr Change to peripheral lock when taking POs Med Order Set Meperidine 50-100 mg IM Q3-4H:PRN Duration: 2 Days Ibuprofen 600 mg PO Q6H:PRN Oxycodone-Acetaminophen 1-2 TAB PO Q4-6H:PRN Ketorolac 15-30 mg IV Q6H:PRN Duration: 3 Days Hydroxyzine HCl 25 mg IM Q3-4H:PRN Lab Page 45 of 59 Admit/Transfer/Postoperative Sets Cardiac Surgery Post-op Orders Allergies Edit Delete Postop orders: Admit to Surgery - Cardiac; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: per protocol click to I & O: Yes Order Monitor urine output: q1h Hemodynamic monitoring click to PA line: in place, transduce Other instructions cardiac output/index q1hr until C.I.>2.0, Order then q4hr Cardiac monitoring Activity click to Order Activity: Activity as tolerated Advance per cardiac rehabilitation Wound Care click to Order Wound care: Site: operative leg Type: Surgical Comment: keep ace wraps on from ankle to thigh x 72 hrs. May change prn. Therapeutic devices/DVT/Prophylaxis Tubes/Drains click to Chest tube to suction 20 cm Order Record chest tube output hourly. click to NGT low continuous suction Order Remove when extubated. Oxygen Therapy click to Oxygen Therapy: After extubation, titrate O2 to keep saturation >92% Order Mechanical Ventilation Mechanical Ventilation: SIMV (Volume Targeted) w/ PS & w/o PS click to Tidal volume (mechanical): 700 cc Respiratory rate: 10 Pressure support level: 5 cm/h2o Order PEEP: 5 cm/h2o FIO2: 100 % Wean per Cardiac Surgery Fast Track Protocol. Weaning Nutrition click to Order Cardiology click to Diet: Start: when extubated Clear liquids Cardiology ECG Page 46 of 59 Admit/Transfer/Postoperative Sets Order General Xray click to CXR upon admission to CSRU Order Radiology General Xray Consults click to Order Other click to Order click to Order click to Order Consults Physical Therapy Soft protective devices on wrists as needed per protocol. Please D/C CVL prior to transfer to floor after peripheral IV access established. D/C Foley catheter on POD #2 IV access IV fluids click to Order Medication click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to 1000ml LR Continuous for 1000 ml Up to 1 liter to maintain C.I. >2.0, then call HO. Med Order Set Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO sedation DC prior to extubation Patient must have adequate airway support prior to administration of dose. Nitroglycerin 0.25-0.6 MCG/KG/MIN IV DRIP TITRATE TO to keep MAP < 90, or at 0.5 mcg/kg/min if radial artery graft Nitroprusside Sodium 0.25-1 MCG/KG/MIN IV DRIP TITRATE TO maintain MAP < 90 Phenylephrine HCl 0.5-5 MCG/KG/MIN IV DRIP TITRATE TO to keep MAP > 60 Glycopyrrolate 0.6 mg IV ONCE:PRN to reverse neuromuscular blockade, if T >36C. May combine with neostigmine in syringe Neostigmine 3 mg IV ONCE:PRN to reverse neuromuscular blockade, if T>36C. May combine with glycopyrrolate in syringe. Potassium Chloride 20 mEq / 50 ml SW IV PRN K<4.4 and CR<2.0 ** Concentrated KCL must be given via central line only ** Calcium Gluconate 2 gm / 100 ml D5W IV PRN Free Cal <1.12 to run over 1 hr. Magnesium Sulfate 2 gm / 100 ml D5W IV PRN mg <2.0 Meperidine 12.5 mg IV PRN shivering May repeat X1. Morphine Sulfate 0.5-4 mg IV Q2H:PRN pain Page 47 of 59 Admit/Transfer/Postoperative Sets Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order Lab click to Order click to Order click to Order Metoclopramide 10 mg IV Q6H:PRN nausea/vomiting Cefazolin 2 gm IV Q8H Duration: 4 Doses if patient is POA Vancomycin HCl 1000 mg IV Q12H Duration: 4 Doses if patient was in hospital pre-operatively Ketorolac 30 mg IM ONCE Duration: 1 Doses hold if Creat>1.2 or >70 years of age Ketorolac 15 mg IM Q6H Duration: 4 Doses Hold if creat >1.2 or >70 years of age Oxycodone-Acetaminophen 1-2 TAB PO Q4H:PRN pain Sucralfate 1 gm NG Q6H Duration: 4 Doses DC after 4 doses or removal of GT Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0 Clopidogrel Bisulfate 300 MG PO/NG ONCE Duration: 1 Doses Start: 4 hrs postop for off-pump CABG if CT output <200 ml over 4 hrs. Clopidogrel Bisulfate 75 MG PO/NG DAILY Duration: 3 Months Start: POD #1 for off-pump CABG Isosorbide Mononitrate 60 mg PO DAILY Start: POD #1 for patients with radial artery graft if NGT discontinued. Aspirin EC 81 mg PO DAILY Start: POD #1 if extubated Aspirin 81 mg NG DAILY Start: POD #1 if intubated. DC when NGT removed. Ranitidine 150 mg PO BID Ranitidine 150 mg NG BID DC when NGT removed. Docusate Sodium 100 mg PO BID Docusate Sodium (Liquid) 100 mg NG BID DC when NGT removed. Insulin Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Blood, To be collected , upon arrival to CSRU, process STAT: Chloride; Bicarbonate; BUN; Creatinine Blood Gases, To be collected , upon arrival to CSRU , process STAT: ABG; Sodium, Whole Blood; Potassium, Whole Blood; Glucose, Whole Blood; Ionized Calcium Blood, To be collected MORNING OF : CBC; Sodium; Potassium; Chloride; Bicarbonate; Glucose; BUN; Creatinine; to be done morning of postop day #1 Page 48 of 59 Admit/Transfer/Postoperative Sets Cardiac Surgery Transfer Orders Allergies Edit Delete Flomax Transfer to Surgery - Cardiac; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: Q 4 hours X 24 hours then Q 8 hours if stable o2 Sats: Daily and PRN Telemetry: Yes click to Weight: qd Order I & O: Yes Fingerstick: Q AC and QHS Incentive spirometry: Q 2 hours while awake Activity click to Order Progress activity per cardiac rehabilitation guidelines. Wound Care Therapeutic devices/DVT/Prophylaxis Tubes/Drains click to Chest tube to suction 20 cm Order Oxygen Therapy click to Oxygen Therapy: Wean o2 keeping saturation >92% Order Nutrition click to Order Consults click to Order Diet: Diabetic/Consistent Carbohydrate, Cardiac/Heart healthy (3-4 gm NA) Consults Physical Therapy Other click to Order click to Order click to Order Temporary Cardiac Pacing: Electronically isolate pacing wires when not in use. Patient to remain in bed for 1 hr after wires removed. Document BP after wire removal. Observe for a minimum of 2 hrs prior to discharge. DC Central venous line on POD #2. DC Foley catheter on POD #2. IV access Page 49 of 59 Admit/Transfer/Postoperative Sets IV fluids Medication click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order Lab click to Order click to Order Med Order Set Metoprolol 25 mg PO BID Furosemide 20 mg PO Q12H * Drug-Allergy Warning * Furosemide 20 mg IV Q12H * Drug-Allergy Warning * Potassium Chloride 20 mEq PO Q12H Docusate Sodium 100 mg PO BID Ranitidine 150 mg PO BID Aspirin EC 81 mg PO DAILY Warfarin MD to order daily dose PO DAILY Insulin Acetaminophen 650 mg PO Q4H:PRN Oxycodone-Acetaminophen 1-2 TAB PO Q4H:PRN pain Morphine Sulfate 1-5 mg SC/IM Q3-4H:PRN pain Milk Of Magnesia 30 ml PO HS:PRN constipation Bisacodyl 10 mg PR DAILY:PRN constipation Clopidogrel Bisulfate 75 MG PO DAILY for off-pump CABG patients x 3 mos. total Isosorbide Mononitrate 60 mg PO DAILY for patients with radial artery graft Cefazolin 2 gm IV Q8H Duration: 4 Doses if patient is POA. 4 doses total Postop - check MAR for dose given in ICU. Vancomycin HCl 1000 mg IV Q12H Duration: 4 Doses if patient inhouse preop. 4 doses total Postop - check MAR for dose given in ICU. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Atorvastatin 10 mg PO DAILY Blood, To be collected MORNING OF , process STAT: CBC; Sodium; Potassium; Chloride; Bicarbonate; Glucose; BUN; Creatinine Daily PT/INR if on Warfarin Blood, To be collected MORNING OF : PT Page 50 of 59 Admit/Transfer/Postoperative Sets Biologics/Oncology Sample Concurrent biochemotherapy in melanoma (off study) High Dose IL-2 Off Protocol *Low Dose IL-2 Off Protocol Maintenance Biotherapy for Metastatic Melanoma Page 51 of 59 Admit/Transfer/Postoperative Sets Low Dose IL-2 Off Protocol Allergies Edit Delete Admit to Medicine - Biologics/Oncology; Attending: SGP YETT,HARRIS; Condition: Good; Vitals/Monitoring Vital signs: q4 click to I & O: Yes Order Call HO if: T>104 ; severe N/V/D, Dyspnea, confusion, or chest pain ; Activity click to Order Nutrition click to Order Activity: Activity as tolerated Diet: House diet General Xray Consults Other click to Order click to Order click to Order click to Order click to Order click to Order Target SBP >= ___________. Weigh Q AM. BC x 2 for T >101.5 after Day 3. PIV x 2 upon admission. NO STEROIDS. Cardiac monitor for all patients while on vasopressors. Patients should D/C all antihypertensive meds at least 24 hours before admission unless otherwise specified. Transfuse 1-2 units PRBC's over 1-3 hrs each unit for hgb<9. Transfuse 1 bag plts over 30 min for plt ct<10K. Labs: Day 1,3,5: CBC with platelets, NA, K, CL, CO2, Ca, Mg, Phos, Glucose, BUN/Creat, ALT, AST, Alk Phos, Total Bili, LD Day 2,4,6: NA, K, CL, C02, BUN/Creat, CK Hold IL-2 for bicarb < 18; see toxicity management/lytes replacement guidelines. Hypotension Guidelines: If SBP < target: 1) Give 250cc NS IV over 15 min, may repeat x 2 (total 3 boluses)*. 2) If SBP remains < target, start Dopamine at 4 mcg/kg/min, ** then call covering NP/MD for further instructions. 3) Adjust dopamine and/or add Neosynephrine per Biologics dosing chart. 4) D/C fluid bolus order for weight gain > 5% over baseline. See Toxicity Management Guidelines *Fluid bolus order may be repeated at each hypotensive episode until weight gain Page 52 of 59 Admit/Transfer/Postoperative Sets exceeds guideline above. ** Use admission weight to calculate dosage. IV access IV fluids click to Order click to Order Medication click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order click to Order 250 ml NS Bolus 250 ml Over 15 mins For SBP < target. May repeat x2 for a total of 3 boluses. D/C this order for weight gain > 5% over baseline. 50 mEq Sodium Bicarbonate/1000 ml D5 1/2 NS Continuous at 75 ml/hr Bicarb replacement: If serum bicarb >=18 and <=20, change IVF to this solution. Once serum bicarb >=21, discontinue IVF. If bicarb <18 and >=16, give 100 mEq IVB and recheck in 1 hr and if < 16, call HO. Med Order Set Indomethacin 25 mg PO Q6H Acetaminophen 650 mg PO Q4H Start at 1pm on Day 1 Ranitidine 150 mg PO BID Lorazepam 1-2 mg PO/IV Q4-6H:PRN nausea or anxiety Meperidine 25-50 mg IV Q2H:PRN rigors in 50 ml D5W over 15 min Diphenhydramine HCl 25-50 mg PO/IV Q6H:PRN pruritis Oxazepam 15-30 mg PO HS:PRN insomnia May repeat X1. Prochlorperazine 10 mg PO/IV Q6H:PRN nausea Diphenoxylate-Atropine 1 TAB PO PRN diarrhea One tab after each loose stool. Max 8 tabs per day. DopAmine 4 mcg/kg/min IV DRIP TITRATE TO keep SBP >= target PRN hypotension that is refractory to fluid boluses. Cardiac monitor while on medication. Phenylephrine HCl 1 mcg/kg/min IV DRIP TITRATE TO keep SBP >= target. PRN if target SBP not met while pt on maximum dopamine dose. Cardiac monitor while on medication. Potassium Chloride PO Sliding Scale Notify HO if K < 3.0 Potassium Chloride IV Sliding Scale Notify HO if K < 3.0 Calcium Replacement (Oncology) IV Sliding Scale Notify HO if Corrected Calcium < = 7.0 Magnesium Sulfate IV Sliding Scale Notify HO if Magnesium <1.2 Potassium Phosphate 15 mmol / 250 ml NS IV PRN for serum phosphate >= 1.5 and <2.4 Infuse over 5 hours If serum phosphate <1.5, call HO. Page 53 of 59 Admit/Transfer/Postoperative Sets Lab Blood tests Done Page 54 of 59 Admit/Transfer/Postoperative Sets Oncology Bone Marrow Transplant Auto Acute Leuk BMT *Conventional Allo: Busulfan/Cytoxan Conventional Allo: Cytoxan/TBI General Auto BMT Orders Non-ECOG Multiple Myeloma Page 55 of 59 Admit/Transfer/Postoperative Sets Conventional Allo: Busulfan/Cytoxan Allergies Admit to Medicine - Hematology/ BMT; Attending: SGP YETT,HARRIS; Condition: Edit Delete Good; BMT protocol: prot name General Orders click to Order Diet: Low bacteria TPN when caloric intake decreases Vital signs: q4 click to Order I & O: Yes Call HO if: SBP <100 or >150 ; DBP>90 ; Record height on admission. click to Order Weigh (kg) daily by 7 AM. Private room, door closed, required due to prolonged neutropenia. Before entering room: Put on mask, wash hands, wear gloves. click to Order Equipment in room for patient only. Incentive spirometer in room. click to Order Consults Physical Therapy click to Order Nutrition consult: BMT admission Labs Blood, To be collected , on afternoon of admission: Sodium; ALT; CBC/DIFF; Potassium; AST; Chloride; Alk Phos; Bicarbonate; Total Bili; Plt Count; Glucose; LD; click to Order BUN; Albumin; PT; Creatinine; PTT; Calcium; Phosphate; Magnesium; Bilirubin, Direct; Protein, Total click to Order To be collected NEXT ROUNDS: Hold Specimen click to Order Urine, To be collected , on afternoon of admission: UA complete w/reflex click to Order Radiology General Xray click to Order EKG to be done on afternoon of admission Ongoing labs: 1. Q day: CBC, diff, plts, BUN, creatinine, electrolytes, Ca, phos, Mg 2. Q Mon, Wed, Fri: AST, bili T/D, uric acid, glucose, albumin, LD, alk phos 3. Q Tues: PT, reticulocyte count, albumin, total protein 4. Q weekly, beginning Day +14 through Day +100: Cytomegalovirus (CMV) Viral Load testing if patient or donor CMV positive. 5. Day 0, then Mon Wed, Fri: Cyclosporine levels from peripheral blood draw. click to Order 6. Additional labs Clot to blood bank q3d. For 1st T >100.5 per day, culture blood from all central line & from a peripheral stick. Call HO. Day -3,-2,-1, then PRN: EKG Day -4 through Day 0: Urine Complete w/ reflex. 7.Before Discharge Obtain: CBC, diff, plts, BUN, creat, electroytes, Mg, Ca, phos, PFT's if plt> 50,000 RBC and Platelet Transfusions Irradiate, WBC-poor at collection or by filtration all blood products (except marrow or stem cells) before administration. click to Order Packed RBC’S for HCT <25 Platelets: If a.m. (or any other) plt count: <20,000/ul: Recheck plts at 5 PM Page 56 of 59 Admit/Transfer/Postoperative Sets <10,000/ul: give one bag plt product. Check post platelet count. If <10,000, repeat procedure above until plts >10,000 Acetaminophen 650 mg PO PRN Premedicate before all blood products click to Order No acetaminophen during chemotherapy. Diphenhydramine HCl 25-50 mg PO/IV PRN only if history of hives with all blood click to Order products Meperidine 25-50 mg IV PRN rigors after blood products click to Order Hold if SBP <90 Bone Marrow and Peripheral Blood Stem Cell Reinfusion Bone Marrow and/or Peripheral Blood Stem Cell Reinfusions: Call transplant nurse to arrange time when marrow/ stem cells will be available Please send STAT type & screen in morning before reinfusion. click to Order Do not radiate or filter marrow or stem cells. Reinfuse stored marrow and/or peripheral blood stem cells EKG, crash cart on floor. click to Order Acetaminophen 650 mg PO PRN premedicate before BM/PBPC reinfusions Diphenhydramine HCl 25-50 mg PO/IV PRN premedicate before BM/PBPC click to Order reinfusions Lorazepam 0.5-1 mg PO/IV PRN premedicate before BM/PBPC reinfusions click to Order PRN and then q3-4h PRN with BM/PBPC reinfusions 50 mEq Sodium Bicarb + 20 mEq Potassium Chl / 1000 mL D5 1/2 NS click to Order Continuous at 350 ml/hr for 1000 ml for 2-3 hrs prior to BM/PBPC reinfusion 50 mEq Sodium Bicarb + 20 mEq Potassium Chl / 1000 mL D5 1/2 NS click to Order Continuous at 200 ml/hr between BM/PBPC reinfusions 50 mEq Sodium Bicarb + 20 mEq Potassium Chl / 1000 mL D5 1/2 NS Continuous at 350 ml/hr for 1000 ml click to Order over 2-3 hours after last BM/PBPC reinfusion. Then revert back to pre-infusion hydration order. Antiemetics Dolasetron Mesylate 100 mg IV PRN click to Order 30 mins prior to chemotherapy then QD for 3 days. click to Order Lorazepam 1 mg IV PRN prior to each dose of busulfan click to Order Lorazepam 1-2 mg IV Q4-6H:PRN after busulfan Supportive Care click to Order Oxazepam 15-30 mg PO HS:PRN click to Order Aluminum Hydroxide Suspension 30 ml PO Q4H:PRN Loperamide HCl 2 mg PO PRN after each loose stool. click to Order For 3 or more loose stools/day. Not to exceed 16 mg per day. Call HO prior to administering for the 1st time. click to Order Multivitamins 1 CAP PO DAILY click to Order Folic Acid 1 mg PO DAILY click to Order BID sitz bath for perianal irritation. Electrolyte Replacement When giving electrolyte replacement, repeat level approximately 2 hrs after click to Order supplementation. click to Order Potassium Chloride PO Sliding Scale Page 57 of 59 Admit/Transfer/Postoperative Sets Call HO for K <3.0 Potassium Chloride IV Sliding Scale click to Order Notify MD if K < 3.0 Magnesium Sulfate IV Sliding Scale click to Order Call HO for MG <1.2 Potassium Phosphate 15 mmol / 250 ml NS IV PRN if serum phosphate >=1.5 and click to Order <2.4 Infuse over 5 hours. If serum phosphate <1.5, call HO. Calcium Replacement (Oncology) IV Sliding Scale click to Order Notify HO if corrected CA <7.0 Antibiotics Except for dosage adjustment, BMT MD on call should approve all changes in click to Order antibiotic regimen. Acyclovir 400 mg IV Q8H click to Order Day minus 2 until discharge. Hold if creatinine >1.5 (See also PO order) Acyclovir 400 mg PO Q8H click to Order Day minus 2 until discharge. Hold if creatinine >1.5 (See also IV order). Sulfameth/Trimethoprim DS 1 TAB PO BID click to Order Start on admission and discontinue on day -3. * Drug-Allergy Warning * Levofloxacin 500 mg PO DAILY click to Order Day -2 until 1st neutropenic spike >=100.5 Fluconazole 200 mg PO BID click to Order Start Day -2 Nystatin Oral Suspension 10 ml PO QID click to Order swish and swallow During Neutropenia (PMN<500) for first T>100.5: Repeat T in 15 minutes. If T >100.5 clearly unassociated with blood product or growth factor administration. click to Order Culture blood from each central access catheter and one peripheral stick. Culture stool, sputum & urine. Portable PA CXR. click to Order Clotrimazole 1 TROC PO 5X/D Sodium Fluoride (Dental Gel) 1 Appl TP HS click to Order to be brushed with toothettes HS Bacitracin 500 mg PO TID click to Order Give with nystatin & polymyxin Start 4 days prior to admission and continue until engraftment. click to Order Chlorhexidine Gluconate 15 ml PO BID Polymyxin B Sulfate 1,000,000 UNIT PO TID click to Order Give with nystatin and bacitracin. Start 4 days prior to admission and continue until engraftment. Nystatin 4 TAB PO TID click to Order Give with polymyxin & bacitracin. Start 4 days prior to admission and continue until engraftment. Hydration/Chemotherapy 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS click to Order Continuous at 100 ml/hr Begin on admission. 6 hrs prior to beginning cyclophosphamide, change rate to 200 Page 58 of 59 Admit/Transfer/Postoperative Sets cc/hr (see additional order). 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS click to Order Continuous at 200 ml/hr Start: 6 hrs prior to beginning cyclophosphamide Continue for 24 hours after cyclophosphamide administration. Use oncology guideline on med screen for dose & frequency click to Order Ursodiol PO Day -2 until discharge Glutamine 10 gm PO TID click to Order Day 0 until discharge. Mixed in a slurry of any PO liquid CycloSPORINE (Continuous Infusion for BMT) IV DRIP INFUSION click to Order Start Day -1 in the morning. Continuous Infusion over 24 hours. Adjust dose per blood levels. Cyclosporin levels: Monitor CSA levels by peripheral blood draw. Start Day 0, then Mon, Wed, Fri. Target CSA level is 475-525 mg/mL. click to Order With any dose changes, CSA levels should be re-checked >=24 hrs following dose change, per BMT MD. Repeat levels when there is a change in LFTs or changing renal function, per BMT MD. Chemotherapy ALL CHEMOTHERAPY MEDICATIONS ARE ON PAPER AND MUST BE click to Order WRITTEN OR COSIGNED BY AN ONCOLOGY ATTENDING. Calculate BSA based on Ht and Wt at admission. Use corrected IBW. click to Order See appendix on paper protocol for formula. Call BMT MD if there is a difference of > 5% from BSA used on orders. Page 59 of 59