/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-96823-en.cckm

201611320

page

100

UWHC,UWMF,

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

CSC Hem BFM Phase 5 (Maintenance) VER 10-3-16 (HL 3245)

CSC Hem BFM Phase 5 (Maintenance) VER 10-3-16 (HL 3245) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM BFM PHASE 5 (MAINTENANCE) VER: 10-3-16 – Properties
Pre-Cycle – 11/8/2016 through 11/14/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/8/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
Consent
Verify Consent
Verify informed consent has been obtained.
Take Home Medications (delete all that do not apply)
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
fluconazole (DIFLUCAN) 200 MG tab
Take 2 tabs by mouth one time daily., 400 mg, Disp-60 tab, R-11, 1 X DAILY starting S, Local Printer
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
senna-docusate (SENOKOT S) 8.6-50 MG per tab
Take 2 tabs by mouth one time daily at bedtime. Skip dose(s) if having loose stools., 2 tab, Disp-60 tab, R-5, 1 X DAILY (HS)
starting S, Local Printer
Counsel patient to purchase over the counter and provide instructions for use.
Cycle 1 – 11/15/2016 through 2/6/2017 (84 days), Planned
Day 1, Cycle 1 – Planned for 11/15/2016
Treatment Plan Information
Reference Information (1)
LEUKEMIA: Gaynon P et al. J Clin Oncol. 1993; 11(11): 2234-42.
Reference Information (2)
See BFM Schedule of Assessments [3549] for lab orders.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 1 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): predniSONE, mercaptopurine, methotrexate,
imatinib (for Philadelphia chromosome positive disease)
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 3.5 tabs by mouth one time daily. Take Day 1 thru 5, Day 29 thru 33, Day 57 thru 61, 70 mg (rounded from 71.6 mg = 40
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
mercaptopurine (PURINETHOL) 50 MG tab
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 2 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take 2.5 tabs by mouth one time daily. Take on Day 1 through 84., 125 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Reduce dose by 25% if patient is on concurrent allopurinol. Round dose up to the nearest 25 mg.
methotrexate 2.5 MG tab
Take 14.5 tabs by mouth once weekly. Take on Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78., 36.25 mg (rounded from 35.8
mg = 20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, EVERY 7 DAYS starting S
Round dose up to the nearest 2.5 mg.
Take Home Medications (delete all that do not apply)
imatinib (GLEEVEC) 400 MG tab
Take by mouth one time daily. Total daily dose = *** mg., R-11, 1 X DAILY starting S, Local Printer
For Philadelphia chromosome positive disease
imatinib (GLEEVEC) 100 MG tab
Take by mouth one time daily. Total daily dose = *** mg., R-11, 1 X DAILY starting S, Local Printer
For Philadelphia chromosome positive disease
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day {LAB DAYS:19668}: LABS: {MAINTENANCE LABS:19667}
MULTIPLE DAY FOLLOW-UP (2)
Day 29 and 57: CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine for 30 minutes
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider and LUMBAR PUNCTURE; LABS: CBC with DIFF,
Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, intrathecal methotrexate, and intrathecal hydrocortisone (if applicable) for
60 minutes and hold for possible platelet transfusion for 90 minutes; PROCEDURE: {LP LOCATION:19662}
Day 29, Cycle 1 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 3 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): predniSONE, mercaptopurine,
methotrexate, imatinib (for Philadelphia chromosome positive disease)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 57, Cycle 1 – Planned for 1/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 4 of 24
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): predniSONE, mercaptopurine,
methotrexate, imatinib (for Philadelphia chromosome positive disease)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 2/7/2017 through 5/1/2017 (84 days), Planned
Day 1, Cycle 2 – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 5 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): predniSONE, mercaptopurine, methotrexate;
Refer to the Cycle 1 Day 1 take home medications section for the following treatment medication(s): imatinib (for Philadelphia
chromosome positive disease)
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 3.5 tabs by mouth one time daily. Take Day 1 thru 5, Day 29 thru 33, Day 57 thru 61, 70 mg (rounded from 71.6 mg = 40
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
mercaptopurine (PURINETHOL) 50 MG tab
Take 2.5 tabs by mouth one time daily. Take on Day 1 through 84., 125 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Reduce dose by 25% if patient is on concurrent allopurinol. Round dose up to the nearest 25 mg.
methotrexate 2.5 MG tab
Take 14.5 tabs by mouth once weekly. Take on Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78., 36.25 mg (rounded from 35.8
mg = 20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, EVERY 7 DAYS starting S
Round dose up to the nearest 2.5 mg.
Follow-Up
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 6 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

MULTIPLE DAY FOLLOW-UP (1)
Day {LAB DAYS:19668}: LABS: {MAINTENANCE LABS:19667}
MULTIPLE DAY FOLLOW-UP (2)
Day 29 and 57: CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine for 30 minutes
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider and LUMBAR PUNCTURE; LABS: CBC with DIFF,
Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, intrathecal methotrexate, and intrathecal hydrocortisone (if applicable) for
60 minutes and hold for possible platelet transfusion for 90 minutes; PROCEDURE: {LP LOCATION:19662}
Day 29, Cycle 2 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 7 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): predniSONE, mercaptopurine,
methotrexate, imatinib (for Philadelphia chromosome positive disease)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 57, Cycle 2 – Planned for 4/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 8 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): predniSONE, mercaptopurine,
methotrexate, imatinib (for Philadelphia chromosome positive disease)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 5/2/2017 through 7/24/2017 (84 days), Planned
Day 1, Cycle 3 – Planned for 5/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 9 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): predniSONE, mercaptopurine, methotrexate;
Refer to the Cycle 1 Day 1 take home medications section for the following treatment medication(s): imatinib (for Philadelphia
chromosome positive disease)
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 3.5 tabs by mouth one time daily. Take Day 1 thru 5, Day 29 thru 33, Day 57 thru 61, 70 mg (rounded from 71.6 mg = 40
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
mercaptopurine (PURINETHOL) 50 MG tab
Take 2.5 tabs by mouth one time daily. Take on Day 1 through 84., 125 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Reduce dose by 25% if patient is on concurrent allopurinol. Round dose up to the nearest 25 mg.
methotrexate 2.5 MG tab
Take 14.5 tabs by mouth once weekly. Take on Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78., 36.25 mg (rounded from 35.8
mg = 20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, EVERY 7 DAYS starting S
Round dose up to the nearest 2.5 mg.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day {LAB DAYS:19668}: LABS: {MAINTENANCE LABS:19667}
MULTIPLE DAY FOLLOW-UP (2)
Day 29 and 57: CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine for 30 minutes
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider and LUMBAR PUNCTURE; LABS: CBC with DIFF,
Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, intrathecal methotrexate, and intrathecal hydrocortisone (if applicable) for
60 minutes and hold for possible platelet transfusion for 90 minutes; PROCEDURE: {LP LOCATION:19662}
Day 29, Cycle 3 – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 10 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY:
vinCRIStine 1.5 mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5,
Day 29 through 33 and Day 57 through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600
mg PO daily (for Philadelphia chromosome positive disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43,
50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone 30 mg IT may be given with IT chemotherapy;
CYCLE LENGTH: 84 days; COURSE: Up to 2 years
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): predniSONE, mercaptopurine,
methotrexate, imatinib (for Philadelphia chromosome positive disease)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 57, Cycle 3 – Planned for 6/27/2017
Treatment Plan Information
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 11 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): predniSONE, mercaptopurine,
methotrexate, imatinib (for Philadelphia chromosome positive disease)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 7/25/2017 through 10/16/2017 (84 days), Planned
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 12 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 4 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 13 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): predniSONE, mercaptopurine, methotrexate;
Refer to the Cycle 1 Day 1 take home medications section for the following treatment medication(s): imatinib (for Philadelphia
chromosome positive disease)
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 3.5 tabs by mouth one time daily. Take Day 1 thru 5, Day 29 thru 33, Day 57 thru 61, 70 mg (rounded from 71.6 mg = 40
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
mercaptopurine (PURINETHOL) 50 MG tab
Take 2.5 tabs by mouth one time daily. Take on Day 1 through 84., 125 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Reduce dose by 25% if patient is on concurrent allopurinol. Round dose up to the nearest 25 mg.
methotrexate 2.5 MG tab
Take 14.5 tabs by mouth once weekly. Take on Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78., 36.25 mg (rounded from 35.8
mg = 20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, EVERY 7 DAYS starting S
Round dose up to the nearest 2.5 mg.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day {LAB DAYS:19668}: LABS: {MAINTENANCE LABS:19667}
MULTIPLE DAY FOLLOW-UP (2)
Day 29 and 57: CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine for 30 minutes
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider and LUMBAR PUNCTURE; LABS: CBC with DIFF,
Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, intrathecal methotrexate, and intrathecal hydrocortisone (if applicable) for
60 minutes and hold for possible platelet transfusion for 90 minutes; PROCEDURE: {LP LOCATION:19662}
Day 29, Cycle 4 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 14 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): predniSONE, mercaptopurine,
methotrexate, imatinib (for Philadelphia chromosome positive disease)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 57, Cycle 4 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 15 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or
Creatinine greater than 1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5
mg/dL or AST greater than or equal to 2.5 X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): predniSONE, mercaptopurine,
methotrexate, imatinib (for Philadelphia chromosome positive disease)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 10/17/2017 through 1/8/2018 (84 days), Planned
Day 1, Cycle 5 – Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 16 of 24
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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): predniSONE, mercaptopurine, methotrexate;
Refer to the Cycle 1 Day 1 take home medications section for the following treatment medication(s): imatinib (for Philadelphia
chromosome positive disease)
Take Home Medications
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 17 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

prednisone (DELTASONE) 20 MG tab
Take 3.5 tabs by mouth one time daily. Take Day 1 thru 5, Day 29 thru 33, Day 57 thru 61, 70 mg (rounded from
71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
mercaptopurine (PURINETHOL) 50 MG tab
Take 2.5 tabs by mouth one time daily. Take on Day 1 through 84., 125 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Reduce dose by 25% if patient is on concurrent allopurinol. Round dose up to the nearest 25 mg.
methotrexate 2.5 MG tab
Take 14.5 tabs by mouth once weekly. Take on Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78., 36.25 mg (rounded from 35.8
mg = 20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, EVERY 7 DAYS starting S
Round dose up to the nearest 2.5 mg.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day {LAB DAYS:19668}: LABS: {MAINTENANCE LABS:19667}
MULTIPLE DAY FOLLOW-UP (2)
Day 29 and 57: CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine for 30 minutes
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider and LUMBAR PUNCTURE; LABS: CBC with DIFF,
Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, intrathecal methotrexate, and intrathecal hydrocortisone (if applicable) for
60 minutes and hold for possible platelet transfusion for 90 minutes; PROCEDURE: {LP LOCATION:19662}
Day 29, Cycle 5 – Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 18 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): predniSONE, mercaptopurine,
methotrexate, imatinib (for Philadelphia chromosome positive disease)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 57, Cycle 5 – Planned for 12/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 19 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): predniSONE, mercaptopurine,
methotrexate, imatinib (for Philadelphia chromosome positive disease)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 1/9/2018 through 4/2/2018 (84 days), Planned
Day 1, Cycle 6 – Planned for 1/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 20 of 24
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): predniSONE, mercaptopurine, methotrexate;
Refer to the Cycle 1 Day 1 take home medications section for the following treatment medication(s): imatinib (for Philadelphia
chromosome positive disease)
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 3.5 tabs by mouth one time daily. Take Day 1 thru 5, Day 29 thru 33, Day 57 thru 61, 70 mg (rounded from 71.6 mg = 40
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
mercaptopurine (PURINETHOL) 50 MG tab
Take 2.5 tabs by mouth one time daily. Take on Day 1 through 84., 125 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Reduce dose by 25% if patient is on concurrent allopurinol. Round dose up to the nearest 25 mg.
methotrexate 2.5 MG tab
Take 14.5 tabs by mouth once weekly. Take on Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78., 36.25 mg (rounded from 35.8
mg = 20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, EVERY 7 DAYS starting S
Round dose up to the nearest 2.5 mg.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day {LAB DAYS:19668}: LABS: {MAINTENANCE LABS:19667}
MULTIPLE DAY FOLLOW-UP (2)
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 21 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 29 and 57: CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine for 30 minutes
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider and LUMBAR PUNCTURE; LABS: CBC with DIFF,
Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, intrathecal methotrexate, and intrathecal hydrocortisone (if applicable) for
60 minutes and hold for possible platelet transfusion for 90 minutes; PROCEDURE: {LP LOCATION:19662}
Day 29, Cycle 6 – Planned for 2/6/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 22 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): predniSONE,
mercaptopurine, methotrexate, imatinib (for Philadelphia chromosome positive disease)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 57, Cycle 6 – Planned for 3/6/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; MAINTENANCE: Begin Day 49 from start of reconsolidation; THERAPY: vinCRIStine 1.5
mg/m2 (maximum dose = 2 mg) IV Day 1, 29 and 57; predniSONE 40 mg/m2 PO Day 1 through 5, Day 29 through 33 and Day 57
through 61; mercaptopurine 75 mg/m2 PO Day 1 through 84; imatinib 400 to 600 mg PO daily (for Philadelphia chromosome positive
disease); methotrexate 20 mg/m2 PO Day 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78; methotrexate 12 mg IT Day 1; hydrocortisone
30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 84 days; COURSE: Up to 2 years
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine greater than
1.5 mg/dL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 1.5 mg/dL or AST greater than or equal to 2.5
X ULN or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit dose if patient took predniSONE at home.
vinCRIStine (ONCOVIN) 2.7 mg in sodium chloride 0.9 % 25 mL bag
2.7 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): predniSONE, mercaptopurine,
methotrexate, imatinib (for Philadelphia chromosome positive disease)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:31:28 PM Page 24 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org