/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-96821-en.cckm

201611326

page

100

UWHC,UWMF,

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

CSC HEM Decitabine(28D:1-10) VER 10-3-16 (HL 1850)

CSC HEM Decitabine(28D:1-10) VER 10-3-16 (HL 1850) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM DECITABINE(28D:1-10) VER: 10-3-16 – Properties
Pre-Cycle – 11/14/2016 through 11/20/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
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
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
Cycle 1 – 11/21/2016 through 12/18/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
ACUTE MYELOGENOUS LEUKEMIA: Blum W, et al. Proc Natl Acad Sci U S A. 2010; 107(16):7473-8
Reference Information (2)
ACUTE MYELOGENOUS LEUKEMIA: Bhatnagar B, et al. Leuk Lymphoma 2014;55(7):1533-7.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 1 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine greater than or
equal to 2 mg/dL or Total Bilirubin greater than or equal to 2.8 mg/dL or ALT greater than or equal to 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Days 2 through 7 and Days 9 and 10: CHEMOTHERAPY ROOM APPOINTMENT: decitabine for 90 minutes
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT; CHEMOTHERAPY ROOM APPOINTMENT: decitabine for 90 minutes
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT;
CHEMOTHERAPY ROOM APPOINTMENT: decitabine for 90 minutes
Day 2, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 2 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 – Planned for 11/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 3 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 1 – Planned for 11/24/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 – Planned for 11/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 4 of 27
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 6, Cycle 1 – Planned for 11/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 5 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 7, Cycle 1 – Planned for 11/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 11/28/2016
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 6 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia,
Myelodysplastic Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days;
COURSE: Continue for at least 3 cycles before determining response or failure
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+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 9, Cycle 1 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 7 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 1 – Planned for 11/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 8 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Normal, 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 1 – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 9 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected-S+12 Approximate, Expires-S+365, Normal, 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/19/2016 through 1/15/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine greater than or
equal to 2 mg/dL or Total Bilirubin greater than or equal to 2.8 mg/dL or ALT greater than or equal to 2 X ULN.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 10 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Days 2 through 7 and Days 9 and 10: CHEMOTHERAPY ROOM APPOINTMENT: decitabine for 90 minutes
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT; CHEMOTHERAPY ROOM APPOINTMENT: decitabine for 90 minutes
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT;
CHEMOTHERAPY ROOM APPOINTMENT: decitabine for 90 minutes
Day 2, Cycle 2 – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 11 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 2 – Planned for 12/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 12 of 27
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.
Day 4, Cycle 2 – Planned for 12/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 2 – Planned for 12/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 13 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 6, Cycle 2 – Planned for 12/24/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 14 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 7, Cycle 2 – Planned for 12/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 2 – Planned for 12/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 15 of 27
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+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 9, Cycle 2 – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 16 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 2 – Planned for 12/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 17 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 2 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 2 – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
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+12 Approximate, Expires-S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/16/2017 through 2/12/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
Consent
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 18 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine greater than or
equal to 2 mg/dL or Total Bilirubin greater than or equal to 2.8 mg/dL or ALT greater than or equal to 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Days 2 through 7 and Days 9 and 10: CHEMOTHERAPY ROOM APPOINTMENT: decitabine for 90 minutes
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT; CHEMOTHERAPY ROOM APPOINTMENT: decitabine for 90 minutes
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 19 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT;
CHEMOTHERAPY ROOM APPOINTMENT: decitabine for 90 minutes
Day 2, Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 3 – Planned for 1/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 20 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 3 – Planned for 1/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 21 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 3 – Planned for 1/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 6, Cycle 3 – Planned for 1/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 22 of 27
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 7, Cycle 3 – Planned for 1/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 23 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 3 – Planned for 1/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
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+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 24 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 9, Cycle 3 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 3 – Planned for 1/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 25 of 27
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 – Planned for 1/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 3 – Planned for 2/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 10; CYCLE LENGTH: 28 days; COURSE: Continue for at least 3
cycles before determining response or failure
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ZZtestonc,Andrew [2428787]
11/21/2016 2:12:55 PM Page 26 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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+12 Approximate, Expires-S+365, Normal, Routine
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]
11/21/2016 2:12:55 PM Page 27 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org