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

/clinical/cckm-tools/content/beacon-protocols/hem---leukemia/name-103863-en.cckm

201611334

page

100

UWHC,UWMF,

Tools,

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

CSC HEM Liposomal Vincristine(28D:1,8,15,22) VER 10-3-16 (HL 6209)

CSC HEM Liposomal Vincristine(28D:1,8,15,22) VER 10-3-16 (HL 6209) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM LIPOSOMAL VINCRISTINE (28D:1,8,15,22) VER: 10-3-16 – Properties
Pre-Cycle – 11/22/2016 through 11/28/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
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
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
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
Take Home Medications (delete all that do not apply)
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily at bedtime., 500 mg, Disp-30 tab, R-5, 1 X DAILY (HS) starting S, Local Printer
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth one time daily as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, 1 X DAILY PRN starting S, Local
Printer
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 1 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 1 – 11/29/2016 through 12/26/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/29/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LEUKEMIA: O'Brien S, et al. J Clin Oncol. 2013;31(6):676-83.
Reference Information (2)
ACUTE LYMPHOBLASTIC LEUKEMIA: Marqibo [package insert]. Hospira Australia Pty Ltd, Mulgrave, Victoria, Australia;2012.
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 2 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Total Bilirubin, AST, ALT and Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine
LIPOSOMAL for 90 minutes.
Day 8, Cycle 1 – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 3 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
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 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 4 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
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 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 5 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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,Andrew [2428787]
11/29/2016 1:21:51 PM Page 6 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/27/2016 through 1/23/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 7 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Total Bilirubin, AST, ALT and Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine
LIPOSOMAL for 90 minutes.
Day 8, Cycle 2 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
IV Access
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 8 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 9 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 1/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 10 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 2 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 11 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/24/2017 through 2/20/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 12 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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]
11/29/2016 1:21:51 PM Page 13 of 35
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Total Bilirubin, AST, ALT and Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine
LIPOSOMAL for 90 minutes.
Day 8, Cycle 3 – Planned for 1/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 14 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 15 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 16 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 3 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 17 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 2/21/2017 through 3/20/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 18 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Total Bilirubin, AST, ALT and Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine
LIPOSOMAL for 90 minutes.
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 19 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 8, Cycle 4 – Planned for 2/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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]
11/29/2016 1:21:51 PM Page 20 of 35
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 21 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 4 – Planned for 3/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 22 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 23 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 3/21/2017 through 4/17/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 24 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Total Bilirubin, AST, ALT and Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine
LIPOSOMAL for 90 minutes.
Day 8, Cycle 5 – Planned for 3/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 25 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 – Planned for 4/4/2017
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 26 of 35
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: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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]
11/29/2016 1:21:51 PM Page 27 of 35
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 5 – Planned for 4/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 28 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 4/18/2017 through 5/15/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
Consent
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 29 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 30 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Total Bilirubin, AST, ALT and Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine
LIPOSOMAL for 90 minutes.
Day 8, Cycle 6 – Planned for 4/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 31 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 – Planned for 5/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
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ZZtestonc,Andrew [2428787]
11/29/2016 1:21:51 PM Page 32 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
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]
11/29/2016 1:21:51 PM Page 33 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 22, Cycle 6 – Planned for 5/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Leukemia (Advanced); THERAPY: vinCRIStine LIPOSOMAL 2.25 mg/m2 IV Days 1, 8, 15 and 22;
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Dose Calculation Instructions
Dose is based on actual body surface area (BSA) and is not capped.
Note to All Staff (1)
Sensory and motor neuropathies are common and are cumulative. Worsening neuropathy requires dose delay, reduction, or
discontinuation of liposomal vincristine.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Total Bilirubin greater than 3 X ULN
or AST greater than 5 X ULN or ALT greater than 5 X ULN or Alkaline Phosphatase greater than 5 X ULN.
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]
11/29/2016 1:21:51 PM Page 34 of 35
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine LIPOSOMAL (MARQIBO) 4 mg in dextrose 5 % 100 mL bag
4 mg (rounded from 4.0275 mg = 2.25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Do not use inline filter. Do not shake. Do not administer with other drugs. Intrathecal administration is
fatal.
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]
11/29/2016 1:21:51 PM Page 35 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org