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CSC HEM Outpt Cladribine (7D:1-7) Ver 11-28-16 (HL 4445)

CSC HEM Outpt Cladribine (7D:1-7) Ver 11-28-16 (HL 4445) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM OUTPT CLADRIBINE(7D:1-7) VER: 11-28-16 – Properties
Pre-Cycle – 11/25/2016 through 12/1/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: cladribine 0.1 mg/kg/day IV as a continuous infusion over 24 hours (Total dose = 0.7
mg/kg over 168 hours); CYCLE LENGTH: 7 days; COURSE: 1 cycle
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
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
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Cycle 1 – 12/2/2016 through 12/9/2016 (8 days), Planned
Day 1, Cycle 1 – Planned for 12/2/2016
Treatment Plan Information
Reference Information (1)
HAIRY CELL LEUKEMIA: Piro LD, et al. N Engl J Med 1990;322(16):1117-21
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: cladribine 0.1 mg/kg/day IV as a continuous infusion over 24 hours (Total dose = 0.7
mg/kg over 168 hours); CYCLE LENGTH: 7 days; COURSE: 1 cycle
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, BUN, Creatinine, Total Bilirubin, AST, ALT, LDH.
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12/2/2016 3:29:56 PM Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority

Treatment Parameters
Hold and notify authorizing prescriber for Creatinine greater than 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
cladribine (LEUSTATIN) home infusion bag 96.6 mg
96.6 mg (0.7 mg/kg × 138 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give as a continuous infusion over 7 days. Dose = 0.1 mg/kg/day: Total dose= 0.7 mg/kg over 168 hours.
Follow-Up
Day 3 Follow-Up
RETURN TO CLINIC: for appointment with provider; LABS: CBC with DIFF, BUN, Creatinine.
Day 8 Follow-Up
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, BUN, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: 30 minutes for pump disconnect.
Day 3 (MD visit), Cycle 1 – Planned for 12/4/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: cladribine 0.1 mg/kg/day IV as a continuous infusion over 24 hours (Total dose = 0.7
mg/kg over 168 hours); CYCLE LENGTH: 7 days; COURSE: 1 cycle
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+2 Approximate, Expires-S+365, Routine
BUN
Expected-S+2 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+2 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, BUN, Creatinine.
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Zztestonc,Fiona F [2462287]
12/2/2016 3:29:56 PM Page 2 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority

Verify Medication(s) Taken at Home (1)
Verify that patient has cladribine pump infusing without difficulty and document in a progress note. Notify
authorizing prescriber if patient has experienced any difficulties with the cladribine infusion.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for signs of neurotoxicity.
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8 (MD visit and Pump Disconnect), Cycle 1 – Planned for 12/9/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: cladribine 0.1 mg/kg/day IV as a continuous infusion over 24 hours (Total dose = 0.7
mg/kg over 168 hours); CYCLE LENGTH: 7 days; COURSE: 1 cycle
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+5 Approximate, Expires-S+365, Routine
BUN
Expected-S+5 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+5 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, BUN, Creatinine.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for signs of neurotoxicity.
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,Fiona F [2462287]
12/2/2016 3:29:56 PM Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority

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
Pump Disconnection Procedures
Disconnect pump upon completion of 168-hour cladribine infusion.
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Zztestonc,Fiona F [2462287]
12/2/2016 3:29:56 PM Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority