/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---leukemia-and-lymphoma/,

/clinical/cckm-tools/content/beacon-protocols/hem---leukemia-and-lymphoma/name-121563-en.cckm

201710289

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Hem - Leukemia and Lymphoma

CSC Hem Arsenic(42D:1-5 Then Twice Weekly Weeks 2-4)/Tretinoin(42D:1-14,29-42) Course 2-4 Low/Intermidate Risk VER 10-12-17 (HL 6505)

CSC Hem Arsenic(42D:1-5 Then Twice Weekly Weeks 2-4)/Tretinoin(42D:1-14,29-42) Course 2-4 Low/Intermidate Risk VER 10-12-17 (HL 6505) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia and Lymphoma


CSC HEM ARSENIC(42D:1-5 THEN TWICE WEEKLY WEEKS 2-4)/TRETINOIN(42D:1-14,29-42) COURSE 2-4
LOW/INTERMEDIATE RISK VER: 10-12-17 –  Properties
Cycle 1 –  10/12/2017 through 11/22/2017 (42 days), Planned
Day 1, Cycle 1 –  Planned for 10/12/2017
Treatment Plan Information
Reference Information (1)
ACUTE PROMYELOCYTIC LEUKEMIA: Burnett A, et al. Lancet Oncol 2015;16(13):1295-1305.
Treatment Plan Summary
DISEASE: Low/Intermediate Risk Acute Promyelocytic Leukemia; THERAPY: arsenic trioxide 0.3 mg/kg IV Day 1 through
5 during Week 1 followed by arsenic trioxide 0.25 mg/kg IV twice weekly during Weeks 2 through 4, tretinoin 22.5
mg/m2 by mouth twice daily Day 1 through 14 and Day 29 through 42; CYCLE LENGTH: 42 days; COURSE: 1 cycle
followed by Course 5 (see HL 6508).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+397, Routine
GLUCOSE
Expected: S Approximate, Expires: S+397, Routine
BUN
Expected: S Approximate, Expires: S+397, Routine
CREATININE
Expected: S Approximate, Expires: S+397, Routine
CALCIUM
Expected: S Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S Approximate, Expires: S+397, Routine
ALT/SGPT
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 1 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Expected: S Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+397, Routine
PROTHROMBIN TIME/INR
Expected: S Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Potassium, Magnesium, Total Bilirubin, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for: Platelets less than 30K/µL or Potassium less than 4 mmol/L or Magnesium
less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or QTc greater than 500
msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 2 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

arsenic trioxide (TRISENOX) 24 mg in sodium chloride 0.9 % 250 mL bag
24 mg (0.3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 120 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each
cycle).
Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take *** mg in AM and *** mg in PM by mouth daily Day 1 through 14 and Day 29 through 42., R-0, starting S, Local
Printer
Total daily dose = 45 mg/m2. Round dose to the nearest 10 mg.
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day 2, 3, 4, and 5: CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for 150 minutes.
DAY 8 FOLLOW-UP
PROCEDURES: weekly ECG; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for 150 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT,
Alkaline Phosphatase; PROCEDURES: weekly ECG; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for 150
minutes.
DAY 18 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for 150 minutes.
DAY 22 FOLLOW-UP
PROCEDURES: weekly ECG; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for 150 minutes.
DAY 25 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for 150 minutes.
DAY 29 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT,
Alkaline Phosphatase.
Day 2, Cycle 1 –  Planned for 10/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Low/Intermediate Risk Acute Promyelocytic Leukemia; THERAPY: arsenic trioxide 0.3 mg/kg IV Day 1 through
5 during Week 1 followed by arsenic trioxide 0.25 mg/kg IV twice weekly during Weeks 2 through 4, tretinoin 22.5
mg/m2 by mouth twice daily Day 1 through 14 and Day 29 through 42; CYCLE LENGTH: 42 days; COURSE: 1 cycle
followed by Course 5 (see HL 6508).
IV Access
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 3 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for QTc greater than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 24 mg in sodium chloride 0.9 % 250 mL bag
24 mg (0.3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each
cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 –  Planned for 10/14/2017
Treatment Plan Information
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 4 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Low/Intermediate Risk Acute Promyelocytic Leukemia; THERAPY: arsenic trioxide 0.3 mg/kg IV Day 1 through
5 during Week 1 followed by arsenic trioxide 0.25 mg/kg IV twice weekly during Weeks 2 through 4, tretinoin 22.5
mg/m2 by mouth twice daily Day 1 through 14 and Day 29 through 42; CYCLE LENGTH: 42 days; COURSE: 1 cycle
followed by Course 5 (see HL 6508).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for QTc greater than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 24 mg in sodium chloride 0.9 % 250 mL bag
24 mg (0.3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each
cycle).
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 5 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 1 –  Planned for 10/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Low/Intermediate Risk Acute Promyelocytic Leukemia; THERAPY: arsenic trioxide 0.3 mg/kg IV Day 1 through
5 during Week 1 followed by arsenic trioxide 0.25 mg/kg IV twice weekly during Weeks 2 through 4, tretinoin 22.5
mg/m2 by mouth twice daily Day 1 through 14 and Day 29 through 42; CYCLE LENGTH: 42 days; COURSE: 1 cycle
followed by Course 5 (see HL 6508).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for QTc greater than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 24 mg in sodium chloride 0.9 % 250 mL bag
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 6 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

24 mg (0.3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each
cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 –  Planned for 10/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Low/Intermediate Risk Acute Promyelocytic Leukemia; THERAPY: arsenic trioxide 0.3 mg/kg IV Day 1 through
5 during Week 1 followed by arsenic trioxide 0.25 mg/kg IV twice weekly during Weeks 2 through 4, tretinoin 22.5
mg/m2 by mouth twice daily Day 1 through 14 and Day 29 through 42; CYCLE LENGTH: 42 days; COURSE: 1 cycle
followed by Course 5 (see HL 6508).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for QTc greater than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 7 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 24 mg in sodium chloride 0.9 % 250 mL bag
24 mg (0.3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each
cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 –  Planned for 10/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Low/Intermediate Risk Acute Promyelocytic Leukemia; THERAPY: arsenic trioxide 0.3 mg/kg IV Day 1 through
5 during Week 1 followed by arsenic trioxide 0.25 mg/kg IV twice weekly during Weeks 2 through 4, tretinoin 22.5
mg/m2 by mouth twice daily Day 1 through 14 and Day 29 through 42; CYCLE LENGTH: 42 days; COURSE: 1 cycle
followed by Course 5 (see HL 6508).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for QTc greater than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 8 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 20 mg in sodium chloride 0.9 % 250 mL bag
20 mg (0.25 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 1 –  Planned for 10/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Low/Intermediate Risk Acute Promyelocytic Leukemia; THERAPY: arsenic trioxide 0.3 mg/kg IV Day 1 through
5 during Week 1 followed by arsenic trioxide 0.25 mg/kg IV twice weekly during Weeks 2 through 4, tretinoin 22.5
mg/m2 by mouth twice daily Day 1 through 14 and Day 29 through 42; CYCLE LENGTH: 42 days; COURSE: 1 cycle
followed by Course 5 (see HL 6508).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for QTc greater than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 9 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 20 mg in sodium chloride 0.9 % 250 mL bag
20 mg (0.25 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 –  Planned for 10/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Low/Intermediate Risk Acute Promyelocytic Leukemia; THERAPY: arsenic trioxide 0.3 mg/kg IV Day 1 through
5 during Week 1 followed by arsenic trioxide 0.25 mg/kg IV twice weekly during Weeks 2 through 4, tretinoin 22.5
mg/m2 by mouth twice daily Day 1 through 14 and Day 29 through 42; CYCLE LENGTH: 42 days; COURSE: 1 cycle
followed by Course 5 (see HL 6508).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+4 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+4 Approximate, Expires: S+397, Routine
GLUCOSE
Expected: S+4 Approximate, Expires: S+397, Routine
BUN
Expected: S+4 Approximate, Expires: S+397, Routine
CREATININE
Expected: S+4 Approximate, Expires: S+397, Routine
CALCIUM
Expected: S+4 Approximate, Expires: S+397, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 10 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

ALBUMIN
Expected: S+4 Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S+4 Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S+4 Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S+4 Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S+4 Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S+4 Approximate, Expires: S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Potassium, Magnesium, Total Bilirubin, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for: Platelets less than 30K/µL or Potassium less than 4 mmol/L or Magnesium
less than 2 mg/dL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 2 mg/dL or QTc greater than 500
msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 11 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Treatment Medications
arsenic trioxide (TRISENOX) 20 mg in sodium chloride 0.9 % 250 mL bag
20 mg (0.25 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 18, Cycle 1 –  Planned for 10/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Low/Intermediate Risk Acute Promyelocytic Leukemia; THERAPY: arsenic trioxide 0.3 mg/kg IV Day 1 through
5 during Week 1 followed by arsenic trioxide 0.25 mg/kg IV twice weekly during Weeks 2 through 4, tretinoin 22.5
mg/m2 by mouth twice daily Day 1 through 14 and Day 29 through 42; CYCLE LENGTH: 42 days; COURSE: 1 cycle
followed by Course 5 (see HL 6508).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for QTc greater than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 12 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 20 mg in sodium chloride 0.9 % 250 mL bag
20 mg (0.25 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 –  Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Low/Intermediate Risk Acute Promyelocytic Leukemia; THERAPY: arsenic trioxide 0.3 mg/kg IV Day 1 through
5 during Week 1 followed by arsenic trioxide 0.25 mg/kg IV twice weekly during Weeks 2 through 4, tretinoin 22.5
mg/m2 by mouth twice daily Day 1 through 14 and Day 29 through 42; CYCLE LENGTH: 42 days; COURSE: 1 cycle
followed by Course 5 (see HL 6508).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for QTc greater than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 13 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 20 mg in sodium chloride 0.9 % 250 mL bag
20 mg (0.25 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 25, Cycle 1 –  Planned for 11/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Low/Intermediate Risk Acute Promyelocytic Leukemia; THERAPY: arsenic trioxide 0.3 mg/kg IV Day 1 through
5 during Week 1 followed by arsenic trioxide 0.25 mg/kg IV twice weekly during Weeks 2 through 4, tretinoin 22.5
mg/m2 by mouth twice daily Day 1 through 14 and Day 29 through 42; CYCLE LENGTH: 42 days; COURSE: 1 cycle
followed by Course 5 (see HL 6508).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for QTc greater than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 14 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 20 mg in sodium chloride 0.9 % 250 mL bag
20 mg (0.25 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 29, Cycle 1 –  Planned for 11/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Low/Intermediate Risk Acute Promyelocytic Leukemia; THERAPY: arsenic trioxide 0.3 mg/kg IV Day 1 through
5 during Week 1 followed by arsenic trioxide 0.25 mg/kg IV twice weekly during Weeks 2 through 4, tretinoin 22.5
mg/m2 by mouth twice daily Day 1 through 14 and Day 29 through 42; CYCLE LENGTH: 42 days; COURSE: 1 cycle
followed by Course 5 (see HL 6508).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+4 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+4 Approximate, Expires: S+397, Routine
GLUCOSE
Expected: S+4 Approximate, Expires: S+397, Routine
BUN
Expected: S+4 Approximate, Expires: S+397, Routine
CREATININE
Expected: S+4 Approximate, Expires: S+397, Routine
CALCIUM
Expected: S+4 Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S+4 Approximate, Expires: S+397, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 15 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

PROTEIN, TOTAL
Expected: S+4 Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S+4 Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S+4 Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S+4 Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S+4 Approximate, Expires: S+397, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/12/2017 8:01:14 AM Page 16 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org