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CSC HEM BFM Phase 2 (Consolidation) VER 3-30-17 (HL 3220)

CSC HEM BFM Phase 2 (Consolidation) VER 3-30-17 (HL 3220) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM BFM PHASE 2 (CONSOLIDATION) VER: 3-30-17 – Properties
Pre-Cycle – 3/23/2017 through 3/29/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 3/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
Consent
Verify Consent
Verify informed consent has been obtained.
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth twice daily on Day 2, 3, 16, and 17 and every 8 hours as needed. Max 3 tabs/day, Disp-30 tab, R-5, starting S,
Local Printer
Take Home Medications (delete all that do not apply)
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
fluconazole (DIFLUCAN) 200 MG tab
Take 2 tabs by mouth one time daily., 400 mg, Disp-60 tab, R-11, 1 X DAILY starting S, Local Printer
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
Cycle 1 – 3/30/2017 through 4/26/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 3/30/2017
Treatment Plan Information
Reference Information (1)
LEUKEMIA: Gaynon P et al. J Clin Oncol. 1993; 11(11): 2234-42.
Reference Information (2)
See BFM Schedule of Assessments [3549] for lab orders.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 1 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST greater than or equal to 2.5 X
ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 30 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mercaptopurine, imatinib (for Philadelphia
chromosome positive disease)
Take Home Medications
mercaptopurine (PURINETHOL) 50 MG tab
Take 60 mg/m2 by mouth one time daily. Take on Day 1 through 28., 60 mg/m2, R-0, 1 X DAILY starting S
Reduce dose by 25% if patient is on concurrent allopurinol. Round dose up to the nearest 25 mg.
Take Home Medications (delete all that do not apply)
imatinib (GLEEVEC) 400 MG tab
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 2 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Take by mouth one time daily. Total daily dose = *** mg., R-11, 1 X DAILY starting S, Local Printer
For Philadelphia chromosome positive disease
imatinib (GLEEVEC) 100 MG tab
Take by mouth one time daily. Total daily dose = *** mg., R-11, 1 X DAILY starting S, Local Printer
For Philadelphia chromosome positive disease
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day ***, *** and ***: LABS: {CONSOLIDATION LABS:19663}
MULTIPLE DAY FOLLOW-UP (2)
Day ***, ***, *** and ***: RETURN TO CLINIC for appointment with HEM RN and LUMBAR PUNCTURE; LABS: Platelets (if not
already drawn); PROCEDURE: {LP LOCATION:19662}
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for cytarabine, intrathecal methotrexate, and intrathecal hydrocortisone (if applicable) for
90 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 9 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine, intrathecal methotrexate, and intrathecal hydrocortisone (if applicable) for
90 minutes
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide for 60 minutes
DAY 16 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine, intrathecal methotrexate, and intrathecal hydrocortisone (if applicable) for
90 minutes
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 18 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 23 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine, intrathecal methotrexate, and intrathecal hydrocortisone (if applicable) for
90 minutes
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 25 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 36 FOLLOW-UP
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 3 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium,
Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase
Day 2, Cycle 1 – Planned for 3/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Treatment Medications
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 4 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Day 3, Cycle 1 – Planned for 4/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 1 – Planned for 4/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 5 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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.
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
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 – Planned for 4/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 6 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 9, Cycle 1 – Planned for 4/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 7 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Treatment Medications
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 1 – Planned for 4/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 8 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Day 11, Cycle 1 – Planned for 4/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 1 – Planned for 4/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 9 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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.
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
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
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 4/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST greater than or equal to 2.5 X
ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 10 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 30 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 16, Cycle 1 – Planned for 4/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 11 of 18
Copyright © 2017 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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Treatment Medications
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 1 – Planned for 4/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 12 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 18, Cycle 1 – Planned for 4/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 13 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 1 – Planned for 4/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 23, Cycle 1 – Planned for 4/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 14 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Treatment Medications
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 1 – Planned for 4/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 15 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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.
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
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 25, Cycle 1 – Planned for 4/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 16 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 1 – Planned for 4/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; CONSOLIDATION: Begin Day 36 from start of induction; THERAPY: cyclophosphamide
1000 mg/m2 IV Day 1 and 15; mercaptopurine 60 mg/m2 PO Day 1 through 28; imatinib 400 to 600 mg PO daily (for Philadelphia
chromosome positive disease); cytarabine 75 mg/m2 IV/subcutaneous Day 2 through 5, Day 9 through 12, Day 16 through 19 and
Day 23 through 26; methotrexate 12 mg IT Day 2, 9, 16 and 23; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient may receive optional cranial XRT (1800 rads in 10 fractions).
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.
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
cytarabine PF (CYTOSAR) injection 75 mg/m2 (Treatment Plan)
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 17 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Fiona F [2462287]
3/30/2017 2:17:07 PM Page 18 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority