B
Pre-Phase Caregiver Plan
BSN · 63M · 96kg · Tata AA1507306
NOT RX

Day 1 — First gentle chemo

Cyclophosphamide + steroid. Baseline labs matter most today.

Morning — before chemo6–10 AM
✓Weight on the same scale, vitals, check ankle swelling & breathlessness
✓Labs: RFT / electrolytes / Ca / PO4 twice daily, plus uric acid, LDH, CBC
✓Fasting sugar check
✓Mouth care — Hexidine gargle twice daily
✓Confirm his thyroid + heart/stent medicines with the doctor. Do not stop the blood thinner without cardiology.
Chemo windowMIDDAY
Inj Granisetron 1 mg IV
Anti-nausea — given before the chemo.
Day 1 & 2 only
Inj Cyclophosphamide 250 mg/m² IV (slow push)
The gentle lead-in chemo. Slow push protects the bladder.
Ward chart shows 500 mg — see Flag 1
Inj Dexamethasone 16 mg IV
Strong steroid — shrinks lymphoma. Will push blood sugar up.
Day 1, 2 & 3
After the injections: vitals every 15 min for 1 hour, then observe ~2 hours for any allergic reaction.
Evening & nightPM
✓Fluids — target per the Tata sheet, but see Flag 2 on his heart
✓Febuxostat (uric acid), Sevelamer (phosphate), Digene (stomach)
✓K-Bind only if potassium is high on the lab
✓Perforation check every 4 hrs — pain score, belly tightness, gas, stool
✓Intake/output chart · sugar before dinner · Clotrimazole lozenges
Watch urine output. Tell the nurse if it drops well below normal for a couple of hours — that's an early TLS warning.

Day 2 — Second dose

Same drugs as Day 1. This is the peak tumour-lysis risk day — labs are critical.

Peak TLS risk day
Why today matters most. Yesterday's chemo is now breaking cancer cells apart fastest. Their contents flood the blood and can strain the kidneys. Today's blood tests and urine output are the most important of the whole prephase.
Morning6–10 AM
✓Same as Day 1 — weight, vitals, sugar, mouth care
✓Labs: RFT/SE/Ca/PO4 twice daily + uric acid + LDH
Chemo windowMIDDAY
Granisetron 1 mg + Cyclophosphamide (2nd dose) + Dexamethasone 16 mg
Same three injections as Day 1, same slow push, same 2-hour observation after.
Final cyclophosphamide dose
Rescue drug — on standby
Rasburicase is kept ready but given only if uric acid rises (the doctor wrote this on the sheet). If uric acid climbs or urine drops, the team may use it. Make sure he is not passing too little urine.
Evening & night
✓Continue Digene, Sevelamer, Febuxostat
✓Perforation check every 4 hrs — do not skip
✓Intake/output chart · blood sugar chart

Day 3 — Steroid only

No chemo today. Steroid continues. Monitoring continues.

Today's injectionsMIDDAY
Inj Dexamethasone 16 mg IV
Steroid only — the final dose of the three.
Day 3 of 3
Continues today
✓Same vitals, weight, labs (RFT/SE/Ca/PO4, uric acid)
✓Blood sugar checks — steroid still raising it
✓Fluids, Digene, Sevelamer (day 3 of 4), Febuxostat
✓Perforation check continues — the bowel stays at risk even after the chemo stops
Discharge planning can begin if…
✓Vitals stable, no fever
✓No signs of perforation
✓Uric acid, potassium, creatinine stable or improving
✓Tolerating fluids, mouth care fine, sugar controlled
What comes next: once the prephase settles, the main treatment (Pola-R-CHP × 6 cycles) begins. Ask the team for the start date.

Diet — 1 week

Two reasons: keep potassium/phosphate low during the TLS window, and avoid any infection risk from raw food.

Strictly avoid — 1 week (Tata rule)
All fruits
Fruit juices
Eggs
Tender coconut / malai
Milk
Curd / dahi
Paneer / cheese
Lassi / chaas
Raw salads / sprouts
Raw coconut chutney
Chaat / pani puri
Outside pickle
Also avoid: street food, leftovers over 2 hrs, fried papad, bakery cream items, unboiled water, raw honey.
This is temporary — about one week, during the tumour-lysis risk window. It is not a permanent diet.
Kitchen rules
✓Everything well-cooked, freshly made, served hot within 2 hours
✓Nothing raw · no outside food · reheat till steaming
✓Boiled or filtered water for drinking and cooking
✓Caregiver handwash 20 sec before cooking and before feeding
✓Separate utensils · his own water bottle · no sharing spoons
✓Limit visitors · nobody with fever or cough near him
Fluids — what he can drink
Boiled cooled water
Jeera water
Ajwain water
Thin strained dal water
Clear strained veg soup
ORS — only if doctor allows
Important: ORS and coconut water contain potassium, which is exactly what's being controlled. Ask before giving either.
How much? The Tata sheet targets 3–4 L/day, but his heart needs this titrated. See Flag 2.
Sample day
Breakfast 8 AM
Soft idli + sambar (well-boiled toor dal & lauki, no coconut, no raw onion)  ·  or upma with soft-boiled carrot  ·  or well-cooked poha with turmeric
Mid-morning 11 AM
Roasted murmura lightly salted + jeera water  ·  or 2 plain Marie biscuits
Lunch 1:30 PM
Rice + thin well-cooked strained toor dal + soft lauki sabzi (no raw tomato) + 1 phulka. Eat slowly, hot.
Evening 4:30 PM
Boiled water + 2–3 plain Marie biscuits  ·  or roasted makhana  ·  or thin strained dal soup
Dinner — light & early 7:30 PM
Soft mushy khichdi (rice + moong dal) with haldi & jeera, 1 tsp oil + well-cooked soft sabzi. Avoid heavy tadka.
Bedtime 9:30 PM
Boiled water only (no milk). Brush, Hexidine gargle, lozenge if prescribed.
Steroid raises blood sugar
✓Dexamethasone will push sugar up, even in someone not diabetic
✓No sugar, jaggery, sweets, or sweet biscuits during these days
✓6 small meals rather than 3 large ones — prevents spikes
✓Max 1 tsp oil per meal · prefer boiled/steamed
✓Never self-adjust his thyroid or heart medicines — tell the nurse instead

Medicines explained

What each one is for, in plain language.

The chemo (injections)
Cyclophosphamide
The gentle lead-in chemotherapy. Given slowly to protect the bladder.
Days 1 & 2
Dexamethasone (Dexa)
A strong steroid that kills lymphoma cells. Side effects: raises blood sugar and blood pressure, can cause fluid retention.
Days 1, 2 & 3
Granisetron (Graniset)
Prevents nausea and vomiting from the chemo.
Days 1 & 2
Kidney & TLS protection
Febuxostat
Lowers uric acid, which surges as cancer cells break down. Protects the kidneys.
7 days
Sevelamer
Binds phosphate in the gut so it doesn't build up in the blood.
4 days
K-Bind
Lowers potassium — only given if a lab shows potassium is high.
As needed
Rasburicase
Powerful uric-acid rescue drug. Kept on standby — the doctor wrote "only if rise in uric acid."
Rescue only
Comfort & infection prevention
Digene
Antacid — protects the stomach, especially with the steroid.
Hexidine mouthwash + Clotrimazole lozenges
Prevent mouth ulcers and fungal infection while immunity is low.
His existing medicines — do not change
Heart / stent medicines (blood thinner): Do not stop or adjust without cardiology. Confirm the plan with the doctor before chemo.
No NSAID painkillers — no ibuprofen, no aspirin-type painkillers, they raise bleeding risk on his blood thinner. Paracetamol only, if the team approves.
Thyroid medicine: continue as prescribed. Never self-adjust.

Flags & red alerts

Two things: emergencies that need action now, and open questions to raise with the team.

🚨 Perforation — call for help immediately
  • Severe belly pain, or pain suddenly getting worse
  • Hard, rigid, or swollen belly / guarding
  • Fever, fast pulse, low BP, feeling faint
  • Vomiting · not passing gas or stool
  • Black tarry stool or blood
  • Sudden relief after severe pain — this can mean rupture
What to do 1. Stop all food and water immediately (NPO)
2. Call the oncologist and the surgeon now
3. Tell them: he is on a blood thinner (clopidogrel), has a heart stent, and has a bowel-wall tumour
4. No laxative or enema without a surgeon
5. Note the time pain started, and whether he passed gas or stool
Also call urgently if…
!Chest pain or breathlessness — given his heart history, never assume it's the tumour. Needs ECG + troponin.
!Passing very little urine for a couple of hours — early kidney/TLS warning
!Fever — infection risk is high during chemo
!Sudden weight gain, ankle swelling, or breathlessness — possible fluid overload on his heart
!Blood sugar very high or very low — tell the nurse, don't self-adjust

Open questions for the team

Things worth confirming — not errors, just gaps to close.

1Cyclophosphamide dose — 250 mg/m² vs the handwritten “500”Confirm
The sheet prints 250 mg/m²; the ward wrote 500. At his size (96 kg / 152 cm, BSA ≈ 2.0 m²), 250 × 2.0 = ~500 mg — so 500 is almost certainly correct, not an error. Worth a quick confirmation, but don't be alarmed.
Ask“Just confirming — the 500 mg written is the calculated dose from 250 mg/m², correct?”
2Fluid target vs his heartImportant
The sheet targets 3–4 L/day to protect the kidneys. But he has a prior heart attack, a stent, and grade I diastolic dysfunction — the exact setting where too much fluid causes trouble. This needs an explicit number from the doctor, not a caregiver guess.
Ask“Given his EF and diastolic dysfunction, what is his actual daily fluid target, and what's the upper limit before we should worry?”
3Blood thinner plan around chemoConfirm
He is on clopidogrel with a coronary stent. Chemo can lower platelets, which raises bleeding risk. This needs a clear plan agreed between cardiology and oncology — and it must not be changed informally.
Ask“What's the plan for his clopidogrel through chemo, and has cardiology signed off? What platelet count would change it?”
4c-Myc FISH resultPending
The FISH gene test has been ordered but not yet resulted. It checks for “double-hit” disease, which would change the regimen. His non-GCB subtype makes the worst version less likely, but the result still matters.
Ask“Is the c-Myc FISH back yet, and when is the reassessment where it factors in?”
5Cycle 1 start date & wherePlan
The main regimen is Pola-R-CHP × 6 cycles, but no start date is written anywhere. Also unclear whether cycles run at Tata or a local centre.
Ask“When does cycle 1 start, will it be inpatient or day-care, and where will the six cycles be given?”
6Stage & prognostic (IPI) scoreAsk
The referral letter left Stage and Prognostic score blank. Not a reason to delay treatment, but worth having.
Ask“What stage and IPI score has he been assigned?”
7CNS prophylaxisAsk
Marked “No” on the referral for the prephase. Given the double-expressor status (c-Myc + Bcl2), worth asking whether it will be reconsidered for the main cycles.
Ask“Will CNS prophylaxis be reconsidered for the main regimen given the double-expressor features?”
8Chart says “63/F” — should be MClerical
The ward prephase sheet records his sex as F. Almost certainly a clerical slip on a busy ward. It won't affect his treatment, but worth flagging to the nurse so records stay clean.
Ask“Small thing — the sheet says 63/F, could that be corrected to M?”
Not a prescription. A caregiver companion built from the Tata Memorial pre-phase sheet (AA1507306) and clinical notes. Doses and instructions follow that sheet — it does not change any treatment. All decisions rest with the treating team. Confirm anything on the Flags tab with the doctor.