PRE-PRINTED PHYSICIAN’S ORDERS
USE BALL POINT PEN ONLY
AN APPROVED THERAPEUTIC/GENERIC EQUIVALENT MAY BE DISPENSED PER
PHARMACY & THERAPEUTICS COMMITTEE GUIDELINES.
PREPRINTED ORDERS FOR: INPATIENT/OUTPATIENT RITUXIMAB TREATMENT
Date Written:
Appointment Day:
Time:
Other _________________________
CD-20 positive non-Hodgkins lymphoma OR:
Diagnosis:
(Page 1 of 1)
Significant Comorbidities: ___________________________________________________
Height:_________cm
Weight:__________kg
NOTE: Orders with option indicator (
) are to be carried out only if checked ()
1.
Lab Work:
2.
PREMEDICATION: (before Rituximab infusion)
3.
BSA________m2
a)
Diphenhydramine (Benadryl) 25 mg IV x 1 dose
b)
Acetaminophen (Tylenol) 650 mg by mouth x 1 dose
c)
IV Normal Saline KVO
CHEMOTHERAPY:
A)
Rituximab ____________ mg IV at 50 mg/hr (100mg/hour for subsequent infusions IF initial dose
was tolerated as per policy) x 30 minutes, then if no hypersensitivity or infusion related events
occur, escalate infusion rate per Rituximab Infusion Policy.
B)
Vital Signs every 15 min x 4, then if stable every 30 min.
C)
Adverse reactions:
1)
Stop Rituximab infusion.
2)
Call Physician.
3)
Normal Saline IV @ 150 ml/hr prn Systolic Blood Pressure less than 90.
4)
Blount Albuterol (Proventil) every 2 hours prn wheezing.
5)
Methylprednisolone (SoluMedrol) 100 mg IV prn upper airway swelling.
6)
Aqueous Epinephrine 1:1000 solution 0.3 ml subcutaneous prn anaphylaxis.
7)
May resume Rituximab infusion at 50% rate after reaction clears, per physician order.
8)
O2 at 2 Liters Per Minute PRN
May give Rituximab by rapid infusion with subsequent doses per hospital rituximab policy
D)
Rapid infusion: total volume 250ml normal saline. Give 20% (50ml) over 30 minutes (100
ml/hour) then remaining 80% (200ml) over 1 hour (200ml/hour).
Physician Signature:
Date/Time:
Revised: 06/2010
Place Patient Label
Inside This Box
Physicians Orders
Inpatient/Outpatient Rituximab
Treatment
Page 1 of 1
7070.03.15003.01

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