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201710286

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CSC Hem INPT/OUTPT Arsenic(60D:1-5 Then Twice Weekly)/Tretinoin(60D:1-60) Course 1 Low/Intermediate Risk VER 10-12-17 (HL 6124)

CSC Hem INPT/OUTPT Arsenic(60D:1-5 Then Twice Weekly)/Tretinoin(60D:1-60) Course 1 Low/Intermediate Risk VER 10-12-17 (HL 6124) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia and Lymphoma


CSC HEM INPT/OUTPT ARSENIC(60D:1-5 THEN TWICE WEEKLY)/TRETINOIN(60D:1-60) COURSE 1
LOW/INTERMEDIATE RISK VER: 10-12-17 –  Properties
Cycle 1 –  10/12/2017 through 12/10/2017 (60 days), Planned
Days 1 through 8, Cycle 1 –  Planned for 10/12/2017 through 10/19/2017
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
Note to All Staff (2)
Consider LP Assessment at start of therapy.
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
EVERY 24 HOURS Starting when released for 7 days, Routine
CBC WITH DIFFERENTIAL
EVERY 72 HOURS Starting S+7 at 0000 for 1 week
COMPREHENSIVE METABOLIC PANEL
EVERY OTHER DAY Starting when released for 1 week
COMPREHENSIVE METABOLIC PANEL
EVERY 72 HOURS Starting S+7 at 0000 for 1 week
URIC ACID
ONCE Starting when released
LD, TOTAL
ONCE Starting when released
CHOLESTEROL
ONCE Starting when released
TRIGLYCERIDE
ONCE Starting when released
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 1 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

PROTHROMBIN TIME/INR
EVERY 24 HOURS Starting when released for 7 days
Draw daily until normalization and then twice weekly thereafter until normal for 2 weeks.
D-DIMER, QUANT
EVERY 24 HOURS Starting when released for 7 days
Draw daily until normalization and then twice weekly thereafter until normal for 2 weeks.
PTT
EVERY 24 HOURS Starting when released for 7 days
Draw daily until normalization and then twice weekly thereafter until normal for 2 weeks.
FIBRINOGEN
EVERY 24 HOURS Starting when released for 7 days
Draw daily until normalization and then twice weekly thereafter until normal for 2 weeks.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Magnesium, Potassium, Total Bilirubin, Creatinine,
Fibrinogen, INR.
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 Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
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
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 2 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

16 mg, Oral, EVERY 24 HOURS, 5 doses Starting when released
Day 1 through 5: Give prior to arsenic.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting S+7 at 0000
Day 8: Give prior to arsenic.
Treatment Medications
tretinoin (VESANOID) cap 40 mg
40 mg (rounded from 44.1 mg = 22.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, 2 X DAILY
(AT MEALTIME) Starting when released
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, EVERY 24 HOURS, For 5 days Starting when
released
Day 1 through 5: Administer over 120 minutes.
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 S+7 at 0000
Day 8: Administer over 120 minutes.
prednisone (DELTASONE) tab 40 mg
40 mg (0.5 mg/kg × 80 kg Treatment plan recorded weight), Oral, EVERY 24 HOURS Starting when released
Give until end of Induction, as differentiation syndrome prophylaxis.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each
cycle).
Conditional Orders
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to
tolerate PO., Administer over 3 Minutes
Total of 24 mg ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 24 mg ondansetron per 24 hours (scheduled and PRN)
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take *** mg in AM and *** mg in PM by mouth daily until instructed to stop by provider., 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
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 20 MG tab
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 3 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Take *** tabs by mouth daily on Days *** through *** of Induction. Total daily dose = ***, R-0, starting S, Local
Printer
prednisone (DELTASONE) 10 MG tab
Take *** tabs by mouth daily on Days *** through *** of Induction. Total daily dose = *** ., R-0, starting S, Local
Printer
prednisone (DELTASONE) 5 MG tab
Take *** tabs by mouth daily on Days *** through *** of Induction. Total daily dose = *** ., R-0, starting S, Local
Printer
Follow-Up
DAY 11 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, PT/INR, PTT, Fibrinogen, D-Dimer; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for
150 minutes.
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, PT/INR, PTT, Fibrinogen, D-Dimer, Total LD,
Cholesterol, Triglycerides; PROCEDURES: weekly ECG; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for 150
minutes.
DAY 18 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, PT/INR, PTT, Fibrinogen, D-Dimer; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for
150 minutes.
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase; LABS (if needed): PT/INR, PTT, Fibrinogen,
D-Dimer; PROCEDURES: weekly ECG; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for 150 minutes.
DAY 25 FOLLOW-UP
LABS: CBC with DIFF; LABS (if needed): PT/INR, PTT, Fibrinogen, D-Dimer; CHEMOTHERAPY ROOM APPOINTMENT:
arsenic trioxide for 150 minutes.
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total LD, Cholesterol, Triglycerides; LABS (if
needed): PT/INR, PTT, Fibrinogen, D-Dimer; PROCEDURES: weekly ECG; CHEMOTHERAPY ROOM APPOINTMENT:
arsenic trioxide for 150 minutes.
DAY 32 FOLLOW-UP
LABS: CBC with DIFF; LABS (if needed): PT/INR, PTT, Fibrinogen, D-Dimer; CHEMOTHERAPY ROOM APPOINTMENT:
arsenic trioxide for 150 minutes.
DAY 36 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase; LABS (if needed): PT/INR, PTT, Fibrinogen,
D-Dimer; PROCEDURES: weekly ECG; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for 150 minutes.
DAY 39 FOLLOW-UP
LABS: CBC with DIFF; LABS (if needed): PT/INR, PTT, Fibrinogen, D-Dimer; CHEMOTHERAPY ROOM APPOINTMENT:
arsenic trioxide for 150 minutes.
DAY 43 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase; LABS (if needed): PT/INR, PTT, Fibrinogen,
D-Dimer; PROCEDURES: weekly ECG; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide for 150 minutes.
DAY 46 FOLLOW-UP
LABS: CBC with DIFF; LABS (if needed): PT/INR, PTT, Fibrinogen, D-Dimer; CHEMOTHERAPY ROOM APPOINTMENT:
arsenic trioxide for 150 minutes.
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 4 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

DAY 50 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase; LABS (if
needed): PT/INR, PTT, Fibrinogen, D-Dimer; PROCEDURES: weekly ECG; CHEMOTHERAPY ROOM
APPOINTMENT: arsenic trioxide for 150 minutes.
DAY 53 FOLLOW-UP
LABS: CBC with DIFF; LABS (if needed): PT/INR, PTT, Fibrinogen, D-Dimer; CHEMOTHERAPY ROOM APPOINTMENT:
arsenic trioxide for 150 minutes.
DAY 57 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase; LABS (if needed): PT/INR, PTT, Fibrinogen,
D-Dimer; PROCEDURES: weekly ECG.
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 5 of 30
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
AST/SGOT
Expected: S Approximate, Expires: S+397, Routine
ALT/SGPT
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, PT/INR,
Fibrinogen, D-Dimer.
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 Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
Nursing Procedure, Assessment and Monitoring
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.
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 6 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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. Give until BM-CR or Day 60.
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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
PROTEIN, TOTAL
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 7 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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
LD, TOTAL
Expected: S+4 Approximate, Expires: S+365, Routine
CHOLESTEROL
Expected: S+4 Approximate, Expires: S+365, Routine
TRIGLYCERIDE
Expected: S+4 Approximate, Expires: S+365, Routine
PROTHROMBIN TIME/INR
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Potassium, Magnesium, Total Bilirubin, Creatinine, PT/INR,
Fibrinogen, D-Dimer.
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 Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
Nursing Procedure, Assessment and Monitoring
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.
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 8 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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) 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. Give until BM-CR or Day 60.
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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+3 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+3 Approximate, Expires: S+397, Routine
GLUCOSE
Expected: S+3 Approximate, Expires: S+397, Routine
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 9 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

BUN
Expected: S+3 Approximate, Expires: S+397, Routine
CREATININE
Expected: S+3 Approximate, Expires: S+397, Routine
CALCIUM
Expected: S+3 Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S+3 Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S+3 Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S+3 Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S+3 Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S+3 Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S+3 Approximate, Expires: S+397, Routine
PROTHROMBIN TIME/INR
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Potassium, Magnesium, Total Bilirubin, Creatinine, PT/INR,
Fibrinogen, D-Dimer.
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 Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 10 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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) 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. Give until BM-CR or Day 60.
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 11 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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
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
Pre-Labs (delete all that do not apply)
PROTHROMBIN TIME/INR
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S+4 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 Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 12 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
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) 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. Give until BM-CR or Day 60.
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 13 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected: S+3 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
PROTHROMBIN TIME/INR
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for: Platelets less than 30K/µL or QTc greater than 500 msec.
Treatment Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
Nursing Procedure, Assessment and Monitoring
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
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 14 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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. Give until BM-CR or Day 60.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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
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
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 15 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

ALT/SGPT
Expected: S+4 Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S+4 Approximate, Expires: S+397, Routine
LD, TOTAL
Expected: S+4 Approximate, Expires: S+365, Routine
CHOLESTEROL
Expected: S+4 Approximate, Expires: S+365, Routine
TRIGLYCERIDE
Expected: S+4 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
PROTHROMBIN TIME/INR
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S+4 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 Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
Nursing Procedure, Assessment and Monitoring
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.
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 16 of 30
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. Give until BM-CR or Day 60.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 32, Cycle 1 –  Planned for 11/12/2017
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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+3 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
PROTHROMBIN TIME/INR
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 17 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for: Platelets less than 30K/µL or QTc greater than 500 msec.
Treatment Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
Nursing Procedure, Assessment and Monitoring
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) 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. Give until BM-CR or Day 60.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 36, Cycle 1 –  Planned for 11/16/2017
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 8, tretinoin 22.5
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 18 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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
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
Pre-Labs (delete all that do not apply)
PROTHROMBIN TIME/INR
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 19 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

D-DIMER, QUANT
Expected: S+4 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 Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
Nursing Procedure, Assessment and Monitoring
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) 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. Give until BM-CR or Day 60.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 39, Cycle 1 –  Planned for 11/19/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 20 of 30
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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+3 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
PROTHROMBIN TIME/INR
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for: Platelets less than 30K/µL or QTc greater than 500 msec.
Treatment Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
Nursing Procedure, Assessment and Monitoring
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.
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 21 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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) 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. Give until BM-CR or Day 60.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 43, Cycle 1 –  Planned for 11/23/2017
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 22 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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
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
Pre-Labs (delete all that do not apply)
PROTHROMBIN TIME/INR
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S+4 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 Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 23 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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) 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. Give until BM-CR or Day 60.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 46, Cycle 1 –  Planned for 11/26/2017
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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+3 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 24 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

PROTHROMBIN TIME/INR
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for: Platelets less than 30K/µL or QTc greater than 500 msec.
Treatment Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
Nursing Procedure, Assessment and Monitoring
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) 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. Give until BM-CR or Day 60.
Follow-Up
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 25 of 30
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 50, Cycle 1 –  Planned for 11/30/2017
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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
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
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 26 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Pre-Labs (delete all that do not apply)
PROTHROMBIN TIME/INR
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S+4 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 Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
Nursing Procedure, Assessment and Monitoring
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) 20 mg in sodium chloride 0.9 % 250 mL bag
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 27 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

20 mg (0.25 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Give until BM-CR or Day 60.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 53, Cycle 1 –  Planned for 12/3/2017
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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+3 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
PROTHROMBIN TIME/INR
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S+3 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for: Platelets less than 30K/µL or QTc greater than 500 msec.
Treatment Parameters (2)
If INR is greater than 1.5 or Fibrinogen less than 150 mg/dL, treat as appropriately with fresh frozen plasma and/or
cryoprecipitate (Coagulation labs will only be drawn daily until normal at start of Course 1, then twice weekly for 2
weeks).
Treatment Condition A
Verify weekly ECG obtained until CR.
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 28 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
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) 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. Give until BM-CR or Day 60.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 57 (Lab Only), Cycle 1 –  Planned for 12/7/2017
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 8, tretinoin 22.5
mg/m2 by mouth twice daily continuously starting Day 1 until complete response (up to max of 60 days), prednisone
0.5 mg/kg by mouth daily as differentiation syndrome prophylaxis until past risk of differentiation syndrome; CYCLE
LENGTH: 56 to 60 days; COURSE: 1 cycle followed by Course 2-4 (see HL 6505).
Note to All Staff (1)
Coagulation labs (PT/INR, PTT, D-Dimer, and Fibrinogen) should be drawn daily until normalization and then twice
weekly thereafter until normal for 2 weeks.
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
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 29 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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
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
Pre-Labs (delete all that do not apply)
PROTHROMBIN TIME/INR
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
PTT
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
FIBRINOGEN
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
D-DIMER, QUANT
Expected: S+4 Approximate, Expires: S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
10/12/2017 8:00:10 AM Page 30 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org