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

/clinical/cckm-tools/content/beacon-protocols/hem---leukemia/name-96819-en.cckm

201611327

page

100

UWHC,UWMF,

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

CSC HEM Pentostatin(28D:1,15) VER 10-3-16 (HL 1761)

CSC HEM Pentostatin(28D:1,15) VER 10-3-16 (HL 1761) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM PENTOSTATIN(28D:1,15) VER: 10-3-16 – Properties
Pre-Cycle – 11/15/2016 through 11/21/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S Approximate, Expires-S+397, Routine
BUN
Expected-S Approximate, Expires-S+397, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
CALCIUM
Expected-S Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, Routine
Take Home Medications
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
Cycle 1 – 11/22/2016 through 12/19/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/22/2016
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 1 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
HAIRY CELL LEUKEMIA: Gever, MJ Clin Oncol 1995;13(4):974-82.
Reference Information (2)
HAIRY CELL LEUKEMIA: Flinn IW, et al. Blood 2000;96(9):2981-6.
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
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, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 100K/µL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pentostatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 2 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
pentostatin (NIPENT) 7.16 mg in sodium chloride 0.9 % 50 mL bag
7.16 mg (4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: pentostatin for
60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: pentostatin for 60 minutes.
Day 15, Cycle 1 – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
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 WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 3 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 100K/µL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pentostatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
pentostatin (NIPENT) 7.16 mg in sodium chloride 0.9 % 50 mL bag
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 4 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

7.16 mg (4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/20/2016 through 1/16/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/20/2016
Treatment Plan Information
Reference Information (1)
HAIRY CELL LEUKEMIA: Gever, M J Clin Oncol 1995;13(4):974-82.
Reference Information (2)
HAIRY CELL LEUKEMIA: Flinn IW, et al. Blood 2000;96(9):2981-6.
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 5 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 100K/µL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pentostatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
pentostatin (NIPENT) 7.16 mg in sodium chloride 0.9 % 50 mL bag
7.16 mg (4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 15 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 6 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if to be done locally), Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: pentostatin for
60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: pentostatin for 60 minutes.
Day 15, Cycle 2 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
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 WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 7 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold and notify authorizing prescriber for Platelets less than or equal to 100K/µL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pentostatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
pentostatin (NIPENT) 7.16 mg in sodium chloride 0.9 % 50 mL bag
7.16 mg (4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/17/2017 through 2/13/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
Reference Information (1)
HAIRY CELL LEUKEMIA: Gever, M J Clin Oncol 1995;13(4):974-82.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 8 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (2)
HAIRY CELL LEUKEMIA: Flinn IW, et al. Blood 2000;96(9):2981-6.
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 100K/µL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 9 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hypersensitivity reaction to pentostatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
pentostatin (NIPENT) 7.16 mg in sodium chloride 0.9 % 50 mL bag
7.16 mg (4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: pentostatin for
60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: pentostatin for 60 minutes.
Day 15, Cycle 3 – Planned for 1/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
IV Access
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 10 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 100K/µL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pentostatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 11 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
pentostatin (NIPENT) 7.16 mg in sodium chloride 0.9 % 50 mL bag
7.16 mg (4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 2/14/2017 through 3/13/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/14/2017
Treatment Plan Information
Reference Information (1)
HAIRY CELL LEUKEMIA: Gever, M J Clin Oncol 1995;13(4):974-82.
Reference Information (2)
HAIRY CELL LEUKEMIA: Flinn IW, et al. Blood 2000;96(9):2981-6.
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 12 of 23
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 WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 100K/µL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pentostatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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,Andrew [2428787]
11/22/2016 12:30:03 PM Page 13 of 23
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
pentostatin (NIPENT) 7.16 mg in sodium chloride 0.9 % 50 mL bag
7.16 mg (4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: pentostatin for
60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: pentostatin for 60 minutes.
Day 15, Cycle 4 – Planned for 2/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
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 WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 14 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 100K/µL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pentostatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 15 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
pentostatin (NIPENT) 7.16 mg in sodium chloride 0.9 % 50 mL bag
7.16 mg (4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 3/14/2017 through 4/10/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/14/2017
Treatment Plan Information
Reference Information (1)
HAIRY CELL LEUKEMIA: Gever, M J Clin Oncol 1995;13(4):974-82.
Reference Information (2)
HAIRY CELL LEUKEMIA: Flinn IW, et al. Blood 2000;96(9):2981-6.
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 16 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 100K/µL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pentostatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 17 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
pentostatin (NIPENT) 7.16 mg in sodium chloride 0.9 % 50 mL bag
7.16 mg (4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: pentostatin for
60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: pentostatin for 60 minutes.
Day 15, Cycle 5 – Planned for 3/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
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 WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 18 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 100K/µL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pentostatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 19 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

pentostatin (NIPENT) 7.16 mg in sodium chloride 0.9 % 50 mL bag
7.16 mg (4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 4/11/2017 through 5/8/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/11/2017
Treatment Plan Information
Reference Information (1)
HAIRY CELL LEUKEMIA: Gever, M J Clin Oncol 1995;13(4):974-82.
Reference Information (2)
HAIRY CELL LEUKEMIA: Flinn IW, et al. Blood 2000;96(9):2981-6.
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 20 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 100K/µL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pentostatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
pentostatin (NIPENT) 7.16 mg in sodium chloride 0.9 % 50 mL bag
7.16 mg (4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 21 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: pentostatin for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: pentostatin for 60 minutes.
Day 15, Cycle 6 – Planned for 4/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hairy Cell Leukemia; THERAPY: pentostatin 4 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: continue
until 2 cycles beyond documentation of complete remission.
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 WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:30:03 PM Page 22 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 100K/µL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pentostatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
pentostatin (NIPENT) 7.16 mg in sodium chloride 0.9 % 50 mL bag
7.16 mg (4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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]
11/22/2016 12:30:03 PM Page 23 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org