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201611333

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CSC HEM INPT OUTPT CALGB 10403 Induction (29D) Ver 11-21-16 (HL 5751)

CSC HEM INPT OUTPT CALGB 10403 Induction (29D) Ver 11-21-16 (HL 5751) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM INPT/OUTPT CALGB 10403 INDUCTION(29D) VER: 11-21-16 – Properties
Cycle 1 Induction – 11/21/2016 through 12/19/2016 (29 days), Planned
Inpatient Days 1 through 4, Cycle 1 Induction – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LEUKEMIA: Stock W, et al. Blood 2014;124(21):796.
Reference Information (2)
ACUTE LYMPHOBLASTIC LEUKEMIA: Advani A, et al. Blood 2013;122(21):3903.
Reference Information (3)
ACUTE LYMPHOBLASTIC LEUKEMIA: National Comprehensive Cancer Network. Acute Lymphoblastic Leukemia (version 2.2014).
http://www.nccn.org/professionals/physician_gls/pdf/all.pdf. Accessed June 9, 2015.
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; INDUCTION THERAPY: cytarabine 70 mg IT Day 1, prednisone 30 mg/m2 by mouth twice
daily Days 1 through 28, DAUNOrubicin 25 mg/m2 IV Day 1, 8, 15, 22, vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1, 8, 15,
22, pegaspargase 2500 units/m2 IM Day 4 (or Day 5 or Day 6), methotrexate (for CNS 1 and 2) 15 mg IT Day 8 and 29 or
methotrexate (for CNS 3) 15 mg IT Day 8, 15, 22, 29; CYCLE LENGTH: 29 days; COURSE: 1 cycle, followed by Extended
Remission Induction OR Consolidation per MD discretion.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
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
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
CREATININE
ONCE Starting when released
BUN
ONCE Starting when released
GLUCOSE
ONCE Starting S+3 at 0000
AMYLASE
ONCE Starting S+3 at 0000
LIPASE
ONCE Starting S+3 at 0000
FIBRINOGEN
ONCE Starting S+3 at 0000
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
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Zztestonc,Jeff J [2507481]
11/21/2016 8:32:59 AM Page 1 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ONCE Starting when released
Treatment Conditions
Verify Labs
Verify the following labs have been obtained: CBC with DIFF, Total Bilirubin, ALT and Creatinine.
Treatment Parameters
Hold and notify authorizing provider for: Total Bilirubin greater than or equal to ULN.
Treatment Condition A
Verify ECHO has been obtained.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Day 4: Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug administration. See
vital signs and emergency medications. There is a 1 hour observation and vital signs period post injection.
Vital Signs
SEE COMMENTS Starting S+3 at 0000 Until Specified
Day 4: Check blood pressure, heart rate, and respiratory rate every 15 minutes during pegaspargase infusion and for 1 hour post-
infusion.
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 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Pre-Medications
NOTE:
ONCE, 1 dose Starting when released
Patient should not receive additional steroids for antiemetic therapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate PO
Give 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting S+3 at 0000
Day 4: Administer prior to pegaspargase.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting S+3 at 0000
Day 4: Administer prior to pegaspargase.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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Zztestonc,Jeff J [2507481]
11/21/2016 8:32:59 AM Page 2 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
cytarabine PF (CYTOSAR) 70 mg in sodium chloride 0.9 % 1.4 mL intraTHECAL injection
70 mg, Intrathecal, ONCE, 1 dose Starting when released
Day 1: Dose to be given by provider.
Treatment Medications
prednisone (DELTASONE) tab 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, 2 X DAILY (AT MEALTIME),
56 doses Starting when released
Administer Day 1 through 28. Do not taper.
DAUNOrubicin (CERUBIDINE) injection 49 mg
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released,
Administer over 15 Minutes
Day 1: IV push into rapid running IV. Administer over 15 minutes.
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Administer over 5 minutes. Max dose = 2 mg.
NOTE:
ONCE, 1 dose Starting when released
Intramuscular route preferred for pegaspargase due to increased incidence of allergic reaction with intravenous route in adults.
pegaspargase (ONCASPAR) injection 4,897.5 units
4,897.5 units (rounded from 4,900 units = 2,500 Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intramuscular,
ONCE, 1 dose Starting S+3 at 0000
DAY 4: Hypersensitivity risk. See Emergency Medications.
Supportive Care Medications
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Starting when released
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
Supportive Care Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, 1 X DAILY, 14 doses Starting when released
Day 1 through 14. For use in patients with moderate to severe risk of tumor lysis syndrome.
Conditional Orders
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.,
Administer over 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:32:59 AM Page 3 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
Take Home Medications
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tablet by mouth twice daily on Saturday and Sunday., Disp-16 tab, R-11, starting S, Local Printer
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
fluconazole (DIFLUCAN) 200 MG tab
Take 2 tabs by mouth one time daily., 400 mg, Disp-60 tab, R-11, 1 X DAILY starting S, Local Printer
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
epINEPHrine (EPIPEN) 0.3 MG/0.3ML soln auto-injector
Give 0.3 mg intramuscularly as needed. Remind patient to bring to clinic., 0.3 mg, R-0, PRN starting S
diphenhydramine (BENADRYL) 25 MG cap
Take 1 cap by mouth every 6 hours as needed for itching (For allergic reaction.). Available over-the-counter., 25 mg, Disp-30
cap, R-1, EVERY 6 HOURS PRN starting S
Take Home Medications (delete all that do not apply)
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tablet by mouth once daily starting on Day *** until ANC greater than *** after nadir., Disp-14 tab, R-0, starting S, Local
Printer
prednisone (DELTASONE) 10 MG tab
Take 6 tabs by mouth 2 times daily at mealtime. Take on Day 1 through 28., 60 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96
m2 Treatment plan BSA from recorded weight), 2 X DAILY (AT MEALTIME) starting S
Do not taper.
prednisone (DELTASONE) 20 MG tab
Take 3 tabs by mouth 2 times daily at mealtime. Take on Day 1 through 28., 60 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96
m2 Treatment plan BSA from recorded weight), 2 X DAILY (AT MEALTIME) starting S
Do not taper.
prednisone (DELTASONE) 50 MG tab
Take 1 tab by mouth 2 times daily at mealtime. Take on Day 1 through 28. Do not taper., 50 mg (rounded from 58.8 mg = 30
mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY (AT MEALTIME) starting S
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth one time daily. Take during Induction Cycle only Days 1 through 14., 300 mg, Disp-14 tab, R-0, 1 X DAILY
starting S, Local Printer
For use in patients with moderate to severe risk of tumor lysis syndrome.
Follow-Up
DAY 8 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Glucose, Amylase, Lipase, Fibrinogen;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine and DAUNOrubicin for 120 minutes, intrathecal methotrexate.
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Glucose, Amylase, Lipase, Fibrinogen;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine and DAUNOrubicin for 120 minutes, CNS3 PATIENTS ONLY for
intrathecal methotrexate.
DAY 22 FOLLOW-UP
30 mg/m2 (58.8 mg = 1.176 tab) cannot be prescribed using the selected product.
The nearest available dose is 50 mg (25.5 mg/m2).
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Zztestonc,Jeff J [2507481]
11/21/2016 8:32:59 AM Page 4 of 10
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; LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine
and DAUNOrubicin for 120 minutes, CNS3 PATIENTS ONLY for intrathecal methotrexate.
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT: for
intrathecal methotrexate.
Day 8, Cycle 1 Induction – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; INDUCTION THERAPY: cytarabine 70 mg IT Day 1, prednisone 30 mg/m2 by mouth twice
daily Days 1 through 28, DAUNOrubicin 25 mg/m2 IV Day 1, 8, 15, 22, vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1, 8, 15,
22, pegaspargase 2500 units/m2 IM Day 4 (or Day 5 or Day 6), methotrexate (for CNS 1 and 2) 15 mg IT Day 8 and 29 or
methotrexate (for CNS 3) 15 mg IT Day 8, 15, 22, 29; CYCLE LENGTH: 29 days; COURSE: 1 cycle, followed by Extended
Remission Induction OR Consolidation per MD discretion.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
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
GLUCOSE
Expected-S Approximate, Expires-S+122, Normal, Routine
AMYLASE
Expected-S Approximate, Expires-S+122, Normal, Routine
LIPASE
Expected-S Approximate, Expires-S+122, Normal, Routine
FIBRINOGEN
Expected-S Approximate, Expires-S+122, Normal, Routine
Treatment Conditions
Verify Labs
Verify the following labs have been obtained: CBC with DIFF.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Jeff J [2507481]
11/21/2016 8:32:59 AM Page 5 of 10
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
NOTE:
ONCE, 1 dose Starting when released
Patient should not receive additional steroids for antiemetic therapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 15 mg in sodium chloride 0.9 % 3 mL intraTHECAL injection
15 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be given by provider.
Treatment Medications
DAUNOrubicin (CERUBIDINE) injection 49 mg
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released,
Administer over 15 Minutes
IV push into rapid running IV. Administer over 15 minutes.
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 5 minutes. Max dose = 2 mg.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): prednisone (dispensed on Day 1).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 Induction – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; INDUCTION THERAPY: cytarabine 70 mg IT Day 1, prednisone 30 mg/m2 by mouth twice
daily Days 1 through 28, DAUNOrubicin 25 mg/m2 IV Day 1, 8, 15, 22, vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1, 8, 15,
22, pegaspargase 2500 units/m2 IM Day 4 (or Day 5 or Day 6), methotrexate (for CNS 1 and 2) 15 mg IT Day 8 and 29 or
methotrexate (for CNS 3) 15 mg IT Day 8, 15, 22, 29; CYCLE LENGTH: 29 days; COURSE: 1 cycle, followed by Extended
Remission Induction OR Consolidation per MD discretion.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:32:59 AM Page 6 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+122, Normal, Routine
AMYLASE
Expected-S+7 Approximate, Expires-S+122, Normal, Routine
LIPASE
Expected-S+7 Approximate, Expires-S+122, Normal, Routine
FIBRINOGEN
Expected-S+7 Approximate, Expires-S+122, Normal, Routine
Treatment Conditions
Verify Labs
Verify the following labs have been obtained: CBC with DIFF.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 15 mg in sodium chloride 0.9 % 3 mL intraTHECAL injection
15 mg, Intrathecal, ONCE, 1 dose Starting when released
FOR PATIENTS WITH CNS3 ONLY: Dose to be given by provider.
Treatment Medications
DAUNOrubicin (CERUBIDINE) injection 49 mg
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released,
Administer over 15 Minutes
IV push into rapid running IV. Administer over 15 minutes.
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 5 minutes. Max dose = 2 mg.
See Take Home Medication(s)
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:32:59 AM Page 7 of 10
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 medication section for the following treatment medication(s): prednisone (dispensed on Day 1).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 Induction – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; INDUCTION THERAPY: cytarabine 70 mg IT Day 1, prednisone 30 mg/m2 by mouth twice
daily Days 1 through 28, DAUNOrubicin 25 mg/m2 IV Day 1, 8, 15, 22, vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1, 8, 15,
22, pegaspargase 2500 units/m2 IM Day 4 (or Day 5 or Day 6), methotrexate (for CNS 1 and 2) 15 mg IT Day 8 and 29 or
methotrexate (for CNS 3) 15 mg IT Day 8, 15, 22, 29; CYCLE LENGTH: 29 days; COURSE: 1 cycle, followed by Extended
Remission Induction OR Consolidation per MD discretion.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify the following labs have been obtained: CBC with DIFF.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Intrathecal Procedure Orders (delete all that do not apply)
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Zztestonc,Jeff J [2507481]
11/21/2016 8:32:59 AM Page 8 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 15 mg in sodium chloride 0.9 % 3 mL intraTHECAL injection
15 mg, Intrathecal, ONCE, 1 dose Starting when released
FOR PATIENTS WITH CNS3 ONLY: Dose to be given by provider.
Treatment Medications
DAUNOrubicin (CERUBIDINE) injection 49 mg
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released,
Administer over 15 Minutes
IV push into rapid running IV. Administer over 15 minutes.
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 5 minutes. Max dose = 2 mg.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): prednisone (dispensed on Day 1).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 1 Induction – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; INDUCTION THERAPY: cytarabine 70 mg IT Day 1, prednisone 30 mg/m2 by mouth twice
daily Days 1 through 28, DAUNOrubicin 25 mg/m2 IV Day 1, 8, 15, 22, vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1, 8, 15,
22, pegaspargase 2500 units/m2 IM Day 4 (or Day 5 or Day 6), methotrexate (for CNS 1 and 2) 15 mg IT Day 8 and 29 or
methotrexate (for CNS 3) 15 mg IT Day 8, 15, 22, 29; CYCLE LENGTH: 29 days; COURSE: 1 cycle, followed by Extended
Remission Induction OR Consolidation per MD discretion.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify the following labs have been obtained: CBC with DIFF.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:32:59 AM Page 9 of 10
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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.
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 15 mg in sodium chloride 0.9 % 3 mL intraTHECAL injection
15 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be given by provider.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): prednisone (dispensed on Day 1).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:32:59 AM Page 10 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org