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201611333

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UWHC,UWMF,

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

CSC HEM ALL CALGB 10403 Consolidation(56D) VER 11-21-16 (HL 5815)

CSC HEM ALL CALGB 10403 Consolidation(56D) VER 11-21-16 (HL 5815) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM ALL CALGB 10403 CONSOLIDATION (56D) VER: 11-21-16 – Properties
Pre-Cycle – 11/14/2016 through 11/20/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+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
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Normal, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S Approximate, Expires-S+365, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 1 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Cycle 1 Consolidation – 11/21/2016 through 1/15/2017 (56 days), Planned
Day 1 , Cycle 1 Consolidation – 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; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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 the following labs have been obtained: CBC with DIFF, Creatinine, and Total Bilirubin.
Treatment Parameters
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 2 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold and notify authorizing provider for: ANC less than 750/uL or Platelets less than 75K/uL or Creatinine greater than or equal to
1.5 X baseline or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 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
cyclophosphamide (CYTOXAN) 1,960 mg in sodium chloride 0.9 % 250 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Take Home Medications
mercaptopurine (PURINETHOL) 50 MG tab
Take *** tab orally daily x*** days and *** tab daily x*** days each week at night on empty stomach. Day 1 through 14., R-0,
starting S
Initial dosing starts at 420 mg/m2/WEEK.
Take Home Medications (delete all that do not apply)
cytarabine PF (CYTOSAR) 100 MG/ML injection
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 3 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Inject cytarabine 75 mg/m2 (*** mg = *** mL) subcutaneous once daily on Days 2 through 4 and Days 8 through 11., R-0, starting
S, Local Printer
Pharmacist to add mL to instructions prior to release.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day 2, 3, 4, 9, 10, 11, 30, 31, 32, 37, 38, and 39: CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total LD,
Phosphate, and Uric Acid; CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 120 minutes and intrathecal methotrexate.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Amylase,
Lipase, Fibrinogen, PT/INR, and PTT; LABS (IF NEEDED): Total LD, Phosphate, and Uric Acid; CHEMOTHERAPY ROOM
APPOINTMENT: vinCRIStine and pegaspargase for 120 minutes; (CNS 1 and CNS 2 PATIENTS ONLY): intrathecal methotrexate
for an additional 30 minutes.
DAY 18 FOLLOW-UP
LABS: Fibrinogen, PT/INR, and PTT.
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Amylase,
Lipase, Fibrinogen, PT/INR, and PTT; LABS (IF NEEDED): Total LD, Phosphate, and Uric Acid; CHEMOTHERAPY ROOM
APPOINTMENT: vinCRIStine for 30 minutes; (CNS 1 and CNS 2 PATIENTS ONLY): intrathecal methotrexate for additional 30
minutes.
DAY 25 FOLLOW-UP
LABS (IF NEEDED): Fibrinogen, PT/INR, and PTT.
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Total
Bilirubin, AST, ALT, Alkaline Phosphatase; LABS (IF NEEDED): Fibrinogen, PT/INR, and PTT; CHEMOTHERAPY ROOM
APPOINTMENT: cyclophosphamide and cytarabine for 240 minutes.
DAY 36 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: cytarabine for 30 minutes.
DAY 43 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Amylase,
Lipase, Fibrinogen, PT/INR, and PTT; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine and pegaspargase for 90 minutes.
DAY 46 FOLLOW-UP
LABS: Fibrinogen, PT/INR, and PTT.
DAY 50 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Amylase,
Lipase, Fibrinogen, PT/INR, and PTT; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine for 30 minutes.
DAY 53 FOLLOW-UP
LABS (IF NEEDED): Fibrinogen, PT/INR, and PTT.
DAY 57 FOLLOW-UP
(Day 1 of Interim Maintenance) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Amylase, Lipase, Fibrinogen, PT/INR, and PTT;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, methotrexate, and intrathecal methotrexate for 90 minutes.
Day 2, Cycle 1 Consolidation – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 4 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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 Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 Consolidation – Planned for 11/23/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 5 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 1 Consolidation – Planned for 11/24/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 6 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 Consolidation – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 7 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+4 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+4 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+4 Approximate, Expires-S+365, Routine
BUN
Expected-S+4 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+4 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+4 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+4 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+4 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+4 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+4 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
Intrathecal Procedure Orders
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 8 of 32
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
Dose to be given by provider.
Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 9, Cycle 1 Consolidation – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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 Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 9 of 32
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.
Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 1 Consolidation – Planned for 11/30/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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 Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
Treatment Medications
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 10 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 1 Consolidation – Planned for 12/1/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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 Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 11 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 Consolidation – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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+4 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+4 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+4 Approximate, Expires-S+365, Routine
BUN
Expected-S+4 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+4 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+4 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+4 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+4 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+4 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 12 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

FIBRINOGEN
Expected-S+4 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+4 Approximate, Expires-S+365, Routine
PTT
Expected-S+4 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
LD, TOTAL
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
PHOSPHATE
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
URIC ACID
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
Treatment Conditions
Verify Labs
Verify the following labs have been obtained: Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for: Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug administration. See vital signs
and emergency medications. Patient should have Epipen and oral diphenhydramine (Benadryl) available for home use.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Check blood pressure, heart rate, and respiratory rate 15 minutes before pegaspargase administration and for 1 hour post-
administration.
Patient Instructions(1)
Verify patient has Epipen to use in clinic for emergency needs.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
diphenhydramine (BENADRYL) cap 25 mg
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 13 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
hydrocortisone sodium succinate PF (SOLU-CORTEF) vial 100 mg
100 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to pegaspargase. Obtain from Accudose.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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
(CNS 1 and CNS 2 PATIENTS ONLY). Dose to be given by provider.
Treatment Medications
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
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 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 when released
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug administration. See vital signs
and emergency medications. Patient should have Epipen and oral diphenhydramine (Benadryl) available for home use.
Take Home Medications
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
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 18, Cycle 1 Consolidation – Planned for 12/8/2016
Treatment Plan Information
Treatment Plan Summary
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 14 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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
FIBRINOGEN
Expected-S+3 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+3 Approximate, Expires-S+365, Routine
PTT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 Consolidation – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 15 of 32
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+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+7 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+7, Expires-S+365, Routine
FIBRINOGEN
Expected-S+7 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+7 Approximate, Expires-S+365, Routine
PTT
Expected-S+7 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
LD, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
PHOSPHATE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
URIC ACID
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
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.
Intrathecal Procedure Orders (delete all that do not apply)
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 16 of 32
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
(CNS 1 and CNS 2 PATIENTS ONLY). Dose to be given by provider.
Treatment Medications
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
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only (If needed) - Day 25, Cycle 1 Consolidation – Planned for 12/15/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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 (delete all that do not apply)
FIBRINOGEN
Expected-S+3 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
PROTHROMBIN TIME/INR
Expected-S+3 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
PTT
Expected-S+3 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29 , Cycle 1 Consolidation – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 17 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1
and 29, cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38,
39, mercaptopurine 420 mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42,
methotrexate for CNS 1 and CNS 2 15 mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8,
vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22, 43 and 50, pegaspargase 2500 units/m2 IM Day 15 and
43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
FIBRINOGEN
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
PROTHROMBIN TIME/INR
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
PTT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
Treatment Conditions
Verify Labs
Verify the following labs have been obtained: CBC with DIFF.
Treatment Parameters
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 18 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold and notify authorizing provider for: ANC less than 750/uL or Platelets less than 75K/uL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
cyclophosphamide (CYTOXAN) 1,960 mg in sodium chloride 0.9 % 250 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Take Home Medications
mercaptopurine (PURINETHOL) 50 MG tab
Take *** tab orally daily x*** days and *** tab daily x*** days each week at night on empty stomach. Day 29 through 42., R-0,
starting S
Initial dosing starts at 420 mg/m2/WEEK.
Take Home Medications (delete all that do not apply)
cytarabine PF (CYTOSAR) 100 MG/ML injection
Inject cytarabine 75 mg/m2 (*** mg = *** mL) subcutaneous once daily on Days 30 through 32 and Days 36 through 39., R-0,
starting S, Local Printer
Pharmacist to add mL to instructions prior to release.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 30, Cycle 1 Consolidation – Planned for 12/20/2016
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 19 of 32
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 Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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 Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 31, Cycle 1 Consolidation – Planned for 12/21/2016
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 20 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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 Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 32, Cycle 1 Consolidation – Planned for 12/22/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 21 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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 Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 36, Cycle 1 Consolidation – Planned for 12/26/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 22 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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+4 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+4 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+4 Approximate, Expires-S+365, Routine
BUN
Expected-S+4 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+4 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+4 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+4 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 23 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 37, Cycle 1 Consolidation – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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 Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 24 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 38, Cycle 1 Consolidation – Planned for 12/28/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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 Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 25 of 32
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): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 39, Cycle 1 Consolidation – Planned for 12/29/2016
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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 Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine 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.
Treatment Medications
cytarabine PF (CYTOSAR) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give IV over 3 to 5 minutes. May give subcutaneous.
See Take Home Medication(s)
Refer to the take home medication section for the following treatment medication(s): mercaptopurine and cytarabine (if administering
at home). (dispensed on Day 1 and 29)
Follow-Up
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 26 of 32
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 43, Cycle 1 Consolidation – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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+4 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+4 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+4 Approximate, Expires-S+365, Routine
BUN
Expected-S+4 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+4 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+4 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+4 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+4 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+4 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+4 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S+4 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 27 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+4 Approximate, Expires-S+365, Routine
PTT
Expected-S+4 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify the following labs have been obtained: Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for: Total Bilirubin greater than ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken mercaptopurine and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug administration. See vital signs
and emergency medications. Patient should have Epipen and oral diphenhydramine (Benadryl) available for home use.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Check blood pressure, heart rate, and respiratory rate 15 minutes before pegaspargase administration and for 1 hour post-
administration.
Patient Instructions(1)
Verify patient has Epipen to use in clinic for emergency needs.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
hydrocortisone sodium succinate PF (SOLU-CORTEF) vial 100 mg
100 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to pegaspargase. Obtain from Accudose.
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 8:37:57 AM Page 28 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 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 when released
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug administration. See vital signs
and emergency medications. Patient should have Epipen and oral diphenhydramine (Benadryl) available for home use.
Take Home Medications
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
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 46, Cycle 1 Consolidation – Planned for 1/5/2017
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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
FIBRINOGEN
Expected-S+3 Approximate, Expires-S+365, Routine
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 8:37:57 AM Page 29 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

PROTHROMBIN TIME/INR
Expected-S+3 Approximate, Expires-S+365, Routine
PTT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 50, Cycle 1 Consolidation – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+7 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 30 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

LIPASE
Expected-S+7, Expires-S+365, Routine
FIBRINOGEN
Expected-S+7 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+7 Approximate, Expires-S+365, Routine
PTT
Expected-S+7 Approximate, Expires-S+365, Routine
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only (If needed) - Day 53, Cycle 1 Consolidation – Planned for 1/12/2017
Treatment Plan Information
Treatment Plan Summary
Disease: Acute Lymphoblastic Leukemia; CONSOLIDATION THERAPY: cyclophosphamide 1000 mg/m2 IV Day 1 and 29,
cytarabine 75 mg/m2 IV or subcutaneous Day 1, 2, 3, 4 and 8, 9, 10, 11 and 29, 30, 31, 32 and 36, 37, 38, 39, mercaptopurine 420
mg/m2/WEEK (dose schedule varies) by mouth Day 1 through 14 and Day 29 through 42, methotrexate for CNS 1 and CNS 2 15
mg IT Day 1, 8, 15, and 22, methotrexate for CNS 3 15 mg IT Day 1 and 8, vincristine 1.5 mg/m2 (max dose = 2 mg) IV Day 15, 22,
43 and 50, pegaspargase 2500 units/m2 IM Day 15 and 43; CYCLE LENGTH: 56 days; COURSE: 1 cycle followed by Interim
Maintenance.
Note to All Staff (1)
Chemotherapy Council approved for patients less than 40 years of age.
Note to All Staff (2)
Therapy should not be interrupted for myelosuppression alone except on Day 29.
IV Access
Insert and Maintain Peripheral IV
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
11/21/2016 8:37:57 AM Page 31 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs (delete all that do not apply)
FIBRINOGEN
Expected-S+3 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
PROTHROMBIN TIME/INR
Expected-S+3 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
PTT
Expected-S+3 Approximate, Expires-S+365, Normal, Routine
Delete if prior result within normal limits.
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 8:37:57 AM Page 32 of 32
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org