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/clinical/cckm-tools/content/beacon-protocols/hem---leukemia/name-96812-en.cckm

201611320

page

100

UWHC,UWMF,

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

CSC Hem BFM Phase 4 (Reinduction) VER 10-3-16 (HL 3229)

CSC Hem BFM Phase 4 (Reinduction) VER 10-3-16 (HL 3229) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM BFM PHASE 4 (REINDUCTION) VER: 10-3-16 – Properties
Pre-Cycle – 11/8/2016 through 11/14/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/8/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 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
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
senna-docusate (SENOKOT S) 8.6-50 MG per tab
Take 2 tabs by mouth one time daily at bedtime. Skip dose(s) if having loose stools., 2 tab, Disp-60 tab, R-5, 1 X DAILY (HS)
starting S, Local Printer
Counsel patient to purchase over the counter and provide instructions for use.
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
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Take Home Medications
epINEPHrine (EPIPEN) 0.3 MG/0.3ML soln auto-injector
Give 0.3 mg intramuscularly as needed. Remind patient to bring to clinic., 0.3 mg, Disp-1 each, R-1, PRN starting S
diphenhydramine (BENADRYL) 12.5 MG/5ML elixir
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 1 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take 20 mL by mouth as needed. Take at first sign of allergic reaction. Available over the counter., 50 mg, PRN
starting S
Cycle 1 – 11/15/2016 through 12/26/2016 (42 days), Planned
Day 1, Cycle 1 – Planned for 11/15/2016
Treatment Plan Information
Reference Information (1)
LEUKEMIA: Gaynon P, et al. J Clin Oncol 1993;11(11): 2234-42.
Reference Information (2)
LEUKEMIA: Douer D, et al. Blood 2007;109:2744-50.
Reference Information (3)
LEUKEMIA; Wetzler M, et al. Blood 2007;109:4164-67.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 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, 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 Total Bilirubin greater
than 1.2 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
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 2 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
dexamethasone (DECADRON) tab 18 mg
18 mg (rounded from 17.9 mg = 10 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took dexamethasone at home.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
**vesicant** Give over 5-10 minutes through running IV line.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): imatinib (for Philadelphia chromosome
positive disease)
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 4.5 tabs by mouth one time daily. Take on Day 2 through 21 then taper as directed. Begin dexamethasone taper on Day
22., 18 mg (rounded from 17.9 mg = 10 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
dexamethasone (DECADRON) 4 MG tab
Starting Day 22. Take 2 tabs daily x3 days then 1 tab daily x3 days then 0.5 tab daily x2 days., Disp-10 tab, R-0, starting S
Take Home Medications (delete all that do not apply)
imatinib (GLEEVEC) 400 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
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
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: pegaspargase for 90 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, BUN, Creatinine, Total Bilirubin, AST, ALT, Lipase, Amylase, Triglycerides; CHEMOTHERAPY ROOM
APPOINTMENT: DOXOrubicin, vinCRIStine for 60 minutes
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, BUN, Creatinine, Total Bilirubin, AST, ALT, Lipase, Amylase, Triglycerides; CHEMOTHERAPY ROOM
APPOINTMENT: DOXOrubicin, vinCRIStine for 60 minutes.
DAY 29 FOLLOW-UP
LABS: CBC with DIFF, BUN, Creatinine, Total Bilirubin, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide
for 60 minutes
DAY 30 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine, intrathecal methotrexate, and intrathecal hydrocortisone (if applicable) for
90 minutes
DAY 31 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 32 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 3 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 33 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 37 FOLLOW-UP
LABS: CBC with DIFF, BUN, Creatinine, Total Bilirubin, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT: cytarabine,
intrathecal methotrexate, and intrathecal hydrocortisone (if applicable) for 90 minutes.
DAY 38 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 39 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 40 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes
DAY 43 FOLLOW-UP
Per treating physician
Day 3, Cycle 1 – Planned for 11/17/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug administration. See vital signs
and emergency medications. Patient should have Epipen and oral diphenhydramine (Benadryl) available for home use.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Check blood pressure, heart rate, and respiratory rate 15 minutes before pegaspargase administration and for 1 hour post-
administration.
Patient Instructions(1)
Verify patient has Epipen to use in clinic for emergency needs.
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 10 UNIT/ML lock flush 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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 4 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
hydrocortisone sodium succinate PF (SOLU-CORTEF) vial 100 mg
100 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to pegaspargase. Obtain from Accudose.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pegaspargase (ONCASPAR) injection 4,477.5 units
4,477.5 units (rounded from 4,475 units = 2,500 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intramuscular,
ONCE, 1 dose Starting when released
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug administration. See vital signs
and emergency medications. Patient to remain in clinic for 1 hour of observation and vital signs post injection. Patient should have
Epipen and oral diphenhydramine (Benadryl) available for home use.
Take Home Medications
epINEPHrine (EPIPEN) 0.3 MG/0.3ML soln auto-injector
Give 0.3 mg intramuscularly as needed. Remind patient to bring to clinic., 0.3 mg, Disp-1 each, R-1, PRN starting S
diphenhydramine (BENADRYL) 12.5 MG/5ML elixir
Take 20 mL by mouth as needed. Take at first sign of allergic reaction. Available over the counter., 50 mg, PRN starting S
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 5 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
BILIRUBIN, TOTAL
Expected-S+5 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+5 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+5 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+5 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+5 Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S+5 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, 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 Total Bilirubin greater
than 1.2 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
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
dexamethasone (DECADRON) tab 18 mg
18 mg (rounded from 17.9 mg = 10 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took dexamethasone at home.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 6 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
**vesicant** Give over 5-10 minutes through running IV line.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
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 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 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+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+7, Expires-S+365, Routine
AMYLASE
Expected-S+7 Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT
Treatment Parameters
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 7 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than 1.2 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
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
dexamethasone (DECADRON) tab 18 mg
18 mg (rounded from 17.9 mg = 10 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took dexamethasone at home.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
**vesicant** Give over 5-10 minutes through running IV line.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 1 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 days; COURSE: 1 cycle.
IV Access
Insert and Maintain Peripheral IV
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 8 of 17
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+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 75K/µL, Creatinine greater than 1.5
mg/dL or Creatinine Clearance less than 60 mL/min, Total Bilirubin greater than 2 mg/dL or AST 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 10 UNIT/ML lock flush 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
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
cyclophosphamide (CYTOXAN) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 30 minutes.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 9 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): thioguanine; Refer to the Day 1 take home
medications section for the following treatment medication(s): imatinib (for Philadelphia chromosome positive disease)
Take Home Medications
thioguanine (TABLOID) 40 MG tab
Take 2.5 tabs by mouth one time daily. Take on Day 29 through 42., 100 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose up to the nearest 20 mg.
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth 2 times daily. Take on Days 30 and 31., 8 mg, Disp-4 tab, R-0, 2 X DAILY starting S, Local Printer
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 30, Cycle 1 – Planned for 12/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 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.
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 10 UNIT/ML lock flush 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)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 10 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), 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 31, Cycle 1 – Planned for 12/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 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.
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 10 UNIT/ML lock flush 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 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), 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,Andrew [2428787]
11/15/2016 3:30:10 PM Page 11 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 32, Cycle 1 – Planned for 12/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 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.
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 10 UNIT/ML lock flush 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 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), 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 33, Cycle 1 – Planned for 12/17/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 days; COURSE: 1 cycle.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 12 of 17
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.
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 10 UNIT/ML lock flush 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 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), 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 37, Cycle 1 – Planned for 12/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 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+4 Approximate, Expires-S+365, Routine
BUN
Expected-S+4 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+4 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+4 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 13 of 17
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+4 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+4 Approximate, Expires-S+365, Routine
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 10 UNIT/ML lock flush 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 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), 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 38, Cycle 1 – Planned for 12/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 days; COURSE: 1 cycle.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 14 of 17
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.
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 10 UNIT/ML lock flush 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 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), 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 39, Cycle 1 – Planned for 12/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 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.
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 10 UNIT/ML lock flush 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,Andrew [2428787]
11/15/2016 3:30:10 PM Page 15 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), 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 40, Cycle 1 – Planned for 12/24/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; REINDUCTION: Begin Day 57 from start of interim maintenance; THERAPY: doxorubicin
25 mg/m2 IV Day 1, 8 and 15; vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 8 and 15; dexamethasone 10 mg/m2 by
mouth Days 1 through 21 then taper; imatinib 400 to 600 mg by mouth once daily (for Philadelphia chromosome positive disease);
pegaspargase 2500 units/m2 IM Day 3; RECONSOLIDATION: Begin Day 29 from start of reinduction; THERAPY:
cyclophosphamide 1000 mg/m2 IV Day 29; thioguanine 60 mg/m2 by mouth Days 29 through 42; cytarabine 75 mg/m2 IV or
subcutaneous Days 30 through 33 and Days 37 through 40; methotrexate 12 mg IT Day 30 and 37; hydrocortisone 30 mg IT may be
given with IT chemotherapy; CYCLE LENGTH: 42 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.
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 10 UNIT/ML lock flush 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 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Give IV over 3-5 minutes. May give subcutaneous if line not available.
Follow-Up
VERIFY APPOINTMENTS
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ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 16 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
ZZtestonc,Andrew [2428787]
11/15/2016 3:30:10 PM Page 17 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org