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

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201611326

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100

UWHC,UWMF,

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

CSC HEM Lenalidomide(28D:1-28) VER 10-3-16 (HL 6203)

CSC HEM Lenalidomide(28D:1-28) VER 10-3-16 (HL 6203) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM LENALIDOMIDE (28D:1-28) VER: 10-3-16 – Properties
Pre-Cycle – 11/14/2016 through 11/20/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
prochlorperazine (COMPAZINE) 10 MG tab
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ZZtestonc,Andrew [2428787]
11/21/2016 3:23:51 PM Page 1 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
Recommended Medication
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide. MD to add order if needed.
Cycle 1 – 11/21/2016 through 12/18/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: List A, et al. N Engl J Med 2006;355(14):1456-65.
Reference Information (2)
MYELODYSPLASTIC SYNDROME: Raza A, et al. Blood 2008;111(1):86-93.
Reference Information (3)
MYELODYSPLASTIC SYNDROME: Revlimid [package insert].Summit, NJ:Celgene Corporation;2015.
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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 (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8, 15, 22, 29 (Day 1 of next
cycle)).
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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:23:51 PM Page 2 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (dispensed Day 1 of each cycle).
Take Home Medications
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take continuously., 10 mg, Disp-28 cap, R-0, 1 X DAILY starting S
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide. MD to add order if needed.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential).
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential).
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, Total LD, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Urine Pregnancy Test (for women of child-bearing potential).
Lab Only - Day 8, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+7 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 12/5/2016
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ZZtestonc,Andrew [2428787]
11/21/2016 3:23:51 PM Page 3 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+14 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 1 – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+21 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/19/2016 through 1/15/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/21/2016 3:23:51 PM Page 4 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:23:51 PM Page 5 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide. MD to add order if needed.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take continuously., 10 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take continuously, 5 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 2.5 MG cap
Take 1 cap by mouth one time daily. Take continuously, 2.5 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test if periods are irregular (for women of child-bearing potential).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, Total LD, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Urine Pregnancy Test (for women of child-bearing potential).
Lab Only - Day 15, Cycle 2 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/16/2017 through 2/12/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/16/2017
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ZZtestonc,Andrew [2428787]
11/21/2016 3:23:51 PM Page 6 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
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,Andrew [2428787]
11/21/2016 3:23:51 PM Page 7 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide. MD to add order if needed.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take continuously., 10 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take continuously, 5 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 2.5 MG cap
Take 1 cap by mouth one time daily. Take continuously, 2.5 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test if periods are irregular (for women of child-bearing potential).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, Total LD, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Urine Pregnancy Test (for women of child-bearing potential).
Lab Only - Day 15, Cycle 3 – Planned for 1/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 2/13/2017 through 3/12/2017 (28 days), Planned
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ZZtestonc,Andrew [2428787]
11/21/2016 3:23:51 PM Page 8 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 4 – Planned for 2/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/21/2016 3:23:51 PM Page 9 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide. MD to add order if needed.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take continuously., 10 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take continuously, 5 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 2.5 MG cap
Take 1 cap by mouth one time daily. Take continuously, 2.5 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test if periods are irregular (for women of child-bearing potential).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, Total LD, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Urine Pregnancy Test (for women of child-bearing potential).
Lab Only - Day 15, Cycle 4 – Planned for 2/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+14 Approximate, Expires-S+365, 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,Andrew [2428787]
11/21/2016 3:23:51 PM Page 10 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 5 – 3/13/2017 through 4/9/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/21/2016 3:23:51 PM Page 11 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide. MD to add order if needed.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take continuously., 10 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take continuously, 5 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 2.5 MG cap
Take 1 cap by mouth one time daily. Take continuously, 2.5 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, LDH, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Urine Pregnancy Test (for women of child-bearing potential).
Cycle 6 – 4/10/2017 through 5/7/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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
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ZZtestonc,Andrew [2428787]
11/21/2016 3:23:51 PM Page 12 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine Clearance less than 60
mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15 and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 29 (Day 1 of next cycle).
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide (dispensed Day 1 of each cycle).
Take Home Medications
Recommended Medication
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide. MD to add order if needed.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take continuously., 10 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
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ZZtestonc,Andrew [2428787]
11/21/2016 3:23:51 PM Page 13 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take continuously, 5 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug
ordering.
lenalidomide (REVLIMID) 2.5 MG cap
Take 1 cap by mouth one time daily. Take continuously, 2.5 mg, Disp-28 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, LDH, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Urine Pregnancy Test (for women of child-bearing potential).
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ZZtestonc,Andrew [2428787]
11/21/2016 3:23:51 PM Page 14 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org