/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-96833-en.cckm

201611327

page

100

UWHC,UWMF,

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

CSC HEM Outpt APML4 Consolidation VER 10-3-16 (HL 5287)

CSC HEM Outpt APML4 Consolidation VER 10-3-16 (HL 5287) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM OUTPT APML4 CONSOLIDATION VER: 10-3-16 – Properties
Pre-Cycle – 11/15/2016 through 11/21/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S Approximate, Expires-S+365, Routine
D-DIMER, QUANT
Expected-S Approximate, Expires-S+122, Routine
PTT
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
SODIUM
Expected-S Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 1 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CALCIUM
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
CHOLESTEROL
Expected-S Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Condition A
Verify weekly ECG obtained.
Take Home Medications
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
fluconazole (DIFLUCAN) 200 MG tab
Take 2 tabs by mouth one time daily., 400 mg, Disp-60 tab, R-5, 1 X DAILY starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
Cycle 1 – 11/22/2016 through 1/9/2017 (49 days), Planned
Day 1, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Reference Information (1)
ACUTE PROMYELOCYTIC LEUKEMIA: Iland HJ, et al. Blood 2012;120(8):1570-80.
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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: Potassium, Magnesium.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 2 of 59
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 Potassium less than 4 mmol/L or Magnesium less than 2 mg/dL
or QTc greater than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take on Days 1 through 28 Consolidation cycle 1. *** mg in the AM and *** mg in the PM, R-0, starting S
Total daily dose = 45mg/m2. Round up to the nearest 10 mg.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 6 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 7 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 3 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 8 FOLLOW-UP
LABS: Potassium and Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 9 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 13 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 14 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. LABS: Potassium and Magnesium; CHEMOTHERAPY ROOM APPOINTMENT:
arsenic trioxide IV for 180 minutes.
DAY 16 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 18 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 20 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 21 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 22 FOLLOW-UP
LABS: Potassium and Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 23 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 25 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 27 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 28 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
MULTIPLE DAY FOLLOW-UP (1)
LABS: Prior to Consolidation cycle 2 (21 to 28 days or 3 to 4 weeks after end of Consolidation cycle 1): CBC with DIFF, PT/INR,
aPTT, Fibrinogen, D-dimer, Glucose, BUN, Creatine, Uric Acid, Total Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Sodium,
Potassium, Calcium, Phosphate, Magnesium, Total Protein, Cholesterol, and Triglycerides.
MULTIPLE DAY FOLLOW-UP (2)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 4 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

RETURN TO CLINIC for appointment with provider Day 1 of Consolidation cycle 2 (21 to 28 days or 3 to 4 weeks after end of
Consolidation cycle 1).
Day 2, Cycle 1 – Planned for 11/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 5 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 3, Cycle 1 – Planned for 11/24/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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 11/25/2016
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 6 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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 11/26/2016
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 7 of 59
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 Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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 11/27/2016
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 8 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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 11/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 9 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 10 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Potassium, Magnesium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Potassium less than 4 mmol/L or Magnesium less than 2 mg/dL or QTc greater
than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 11 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 9, Cycle 1 – Planned for 11/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 12 of 59
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 10, Cycle 1 – Planned for 12/1/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 13 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 11, Cycle 1 – Planned for 12/2/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 1 – Planned for 12/3/2016
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 14 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 13, Cycle 1 – Planned for 12/4/2016
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 15 of 59
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 Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY:
tretinoin 22.5 mg/m2 by mouth twice daily Days 1 through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15
mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through
33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289. Note (1): Consolidation
begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days (3 to 4
weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 14, Cycle 1 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 16 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 17 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Potassium, Magnesium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Potassium less than 4 mmol/L or Magnesium less than 2 mg/dL or QTc greater
than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 18 of 59
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.
Day 16, Cycle 1 – Planned for 12/7/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 19 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 1 – Planned for 12/8/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 20 of 59
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 18, Cycle 1 – Planned for 12/9/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 21 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 19, Cycle 1 – Planned for 12/10/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 20, Cycle 1 – Planned for 12/11/2016
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 22 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 21, Cycle 1 – Planned for 12/12/2016
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 23 of 59
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 Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by
mouth twice daily continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE
LENGTH: 28 days; COURSE: 1 cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY:
tretinoin 22.5 mg/m2 by mouth twice daily Days 1 through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15
mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through
33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289. Note (1): Consolidation
begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days (3 to 4
weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 24 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Potassium, Magnesium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Potassium less than 4 mmol/L or Magnesium less than 2 mg/dL or QTc greater
than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 25 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 23, Cycle 1 – Planned for 12/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 26 of 59
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.
Day 24, Cycle 1 – Planned for 12/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 27 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 25, Cycle 1 – Planned for 12/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 28 of 59
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 26, Cycle 1 – Planned for 12/17/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 29 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 27, Cycle 1 – Planned for 12/18/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 28, Cycle 1 – Planned for 12/19/2016
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 30 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Days 1 through 28.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 1/10/2017 through 2/13/2017 (35 days), Planned
Day 1, Cycle 2 – Planned for 1/10/2017
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 31 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S Approximate, Expires-S+365, Routine
D-DIMER, QUANT
Expected-S Approximate, Expires-S+122, Routine
PROTHROMBIN TIME/INR
Expected-S Approximate, Expires-S+365, Routine
PTT
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
SODIUM
Expected-S Approximate, Expires-S+365, Routine
POTASSIUM
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 32 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
CHOLESTEROL
Expected-S Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Potassium, Magnesium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Potassium less than 4 mmol/L or Magnesium less than 2 mg/dL or QTc greater
than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 33 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take Home Medications
tretinoin (VESANOID) 10 MG cap
Take on Days 1 to 7, 15 to 21, 29 to 35 of Consolidation cycle 2. *** mg in the AM and *** mg in the PM, R-0, starting S
Total daily dose = 45mg/m2. Round up to the nearest 10 mg.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 8 FOLLOW-UP
LABS: Potassium and Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 9 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 15 FOLLOW-UP
LABS: Potassium and Magnesium; RETURN TO CLINIC for appointment with provider. CHEMOTHERAPY ROOM APPOINTMENT:
arsenic trioxide for 180 minutes.
DAY 16 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 18 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 22 FOLLOW-UP
LABS: Potassium and Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 23 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 25 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 29 FOLLOW-UP
LABS: Potassium and Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 30 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 34 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 31 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 32 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
DAY 33 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: arsenic trioxide IV for 180 minutes.
MULTIPLE DAY FOLLOW-UP (1)
LABS: Prior to Maintenance (21 to 28 days or 3 to 4 weeks after end of Consolidation): CBC with DIFF, Creatinine, Total Bilirubin,
AST and ALT.
MULTIPLE DAY FOLLOW-UP (2)
RETURN TO CLINIC for appointment with provider for Day 1 of Maintenance (21 to 28 days or 3 to 4 weeks after end of
Consolidation).
Day 2, Cycle 2 – Planned for 1/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 35 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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 1/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 36 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 2 – Planned for 1/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 37 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through
26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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 1/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 38 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
POTASSIUM
Expected-S+3 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Potassium, Magnesium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Potassium less than 4 mmol/L or Magnesium less than 2 mg/dL or QTc greater
than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor for retinoic acid syndrome: hyperleukocytosis, fever, dyspnea, acute respiratory distress and weight gain. Hold dose and
notify MD.
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]
11/22/2016 12:24:21 PM Page 39 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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 1/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 40 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
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 1/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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]
11/22/2016 12:24:21 PM Page 41 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 2 – Planned for 1/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 42 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 2 – Planned for 1/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 43 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
POTASSIUM
Expected-S+3 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Potassium, Magnesium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Potassium less than 4 mmol/L or Magnesium less than 2 mg/dL or QTc greater
than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor for retinoic acid syndrome: hyperleukocytosis, fever, dyspnea, acute respiratory distress and weight gain. Hold dose and
notify MD.
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.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 44 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 16, Cycle 2 – Planned for 1/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 45 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 2 – Planned for 1/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 46 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 18, Cycle 2 – Planned for 1/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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]
11/22/2016 12:24:21 PM Page 47 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 2 – Planned for 1/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 48 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 2 – Planned for 1/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
POTASSIUM
Expected-S+3 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Potassium, Magnesium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Potassium less than 4 mmol/L or Magnesium less than 2 mg/dL or QTc greater
than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor for retinoic acid syndrome: hyperleukocytosis, fever, dyspnea, acute respiratory distress and weight gain. Hold dose and
notify MD.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 49 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 23, Cycle 2 – Planned for 2/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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]
11/22/2016 12:24:21 PM Page 50 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 2 – Planned for 2/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 51 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 25, Cycle 2 – Planned for 2/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 52 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 2 – Planned for 2/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 53 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 2 – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
POTASSIUM
Expected-S+3 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Potassium, Magnesium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Potassium less than 4 mmol/L or Magnesium less than 2 mg/dL or QTc greater
than 500 msec.
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 54 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Monitor for retinoic acid syndrome: hyperleukocytosis, fever, dyspnea, acute respiratory distress and weight gain. Hold dose and
notify MD.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 30, Cycle 2 – Planned for 2/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 55 of 59
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 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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 31, Cycle 2 – Planned for 2/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 56 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 32, Cycle 2 – Planned for 2/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 57 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 33, Cycle 2 – Planned for 2/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Promyelocytic Leukemia (High Risk); CONSOLIDATION THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily
continuously Days 1 through 28, arsenic trioxide 0.15 mg/kg IV daily Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by 21 to 28 days (3 to 4 weeks) therapy free followed by THERAPY: tretinoin 22.5 mg/m2 by mouth twice daily Days 1
through 7, 15 through 21, 29 through 35, arsenic trioxide 0.15 mg/kg IV daily (Monday through Friday) Days 1 through 5, 8 through
12, 15 through 19, 22 through 26, 29 through 33; CYCLE LENGTH: 35 days; COURSE: 1 cycle followed by Maintenance HL# 5289.
Note (1): Consolidation begins 21 to 28 days (3 to 4 weeks) after the end of Induction. Note (2): Maintenance begins 21 to 28 days
(3 to 4 weeks) after end of Consolidation.
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
Treatment Condition A
Verify weekly ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient for Retinoic Acid Syndrome/ Differentiation Syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 58 of 59
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
arsenic trioxide (TRISENOX) 10.5 mg in sodium chloride 0.9 % 250 mL bag
10.5 mg (0.15 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. Monday through Friday Days 1 through 5, 8 through 12, 15 through 19, 22 through 26, 29 through 33.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: tretinoin (dispensed Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:24:21 PM Page 59 of 59
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org