/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/,

/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/name-96850-en.cckm

201611326

page

100

UWHC,UWMF,

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

CSC HEM Escalated BEACOPP VER 10-3-16 (HL 5277)

CSC HEM Escalated BEACOPP VER 10-3-16 (HL 5277) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM ESCALATED BEACOPP VER: 10-3-16 – Properties
Pre-Cycle – 11/14/2016 through 11/20/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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+397, Routine
GLUCOSE
Expected-S Approximate, Expires-S+397, Routine
BUN
Expected-S Approximate, Expires-S+397, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
CALCIUM
Expected-S Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 1 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth one time daily. Take during Cycle 1 only., 300 mg, Disp-10 tab, R-0, 1 X DAILY starting S,
Local Printer
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
fluconazole (DIFLUCAN) 200 MG tab
Take 2 tabs by mouth one time daily., 400 mg, Disp-60 tab, R-5, 1 X DAILY starting S, Local Printer
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tablet by mouth twice daily on Saturday and Sunday., Disp-16 tab, R-5, starting S
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day 8. Continue until ANC is greater than 1000/µL after nadir, 300
mcg, Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day 8. Continue until ANC is greater than 1000/µL after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 – 11/21/2016 through 12/11/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
HODGKIN'S LYMPHOMA: Diehl V, et al. N Eng J Med 2003;348(24):2386-95.
Reference Information (2)
HODGKIN'S LYMPHOMA: Engert A, et al. J Clin Oncol 2009;27(27):4548-54.
Reference Information (3)
HODGKIN'S LYMPHOMA: Skoetz N, et al. Lancet Oncol 2013;14(10):943-52.
Reference Information (4)
HODGKIN'S LYMPHOMA: Engert A, et al. Lancet 2012;379(9828):1791-9.
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 2 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Total Bilirubin
greater than ULN or Creatinine Clearance less than 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Patient Instructions(2)
RN to instruct patient regarding food interactions with procarbazine.
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% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Administer prior to treatment.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 63 mg
63 mg (rounded from 62.65 mg = 35 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 2,148 mg in sodium chloride 0.9 % 250 mL bag
2,148 mg (1,200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
procarbazine (MATULANE) cap 200 mg
200 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Use patient's own supply.
100 mg/m2 (179 mg) cannot be administered using available products.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 3 of 39
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 medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Take Home Medications
procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily at bedtime. Take on Days 1 through 7 of Cycle., 200 mg (rounded from 179 mg = 100
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY (HS) starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 10 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 70 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 20 MG tab
Take 3.5 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 70 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 50 MG tab
Take 1.5 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 75 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for etoposide for 120 minutes.
DAY 3 FOLLOW-UP
LABS: Creatinine, Potassium, Uric Acid, LDH; CHEMOTHERAPY ROOM APPOINTMENT for etoposide for 120 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid; CHEMOTHERAPY ROOM APPOINTMENT for
bleomycin and vinCRIStine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, AST, ALT, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide, and
etoposide for 240 minutes.
Day 2, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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 prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 4 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify that patient has taken procarbazine 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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 – Planned for 11/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 5 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

URIC ACID
Expected-S+1 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
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.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken procarbazine 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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 6 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+5 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+5 Approximate, Expires-S+365, Routine
BUN
Expected-S+5 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+5 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+5 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+21, Expires-S+365, Routine
Treatment Conditions
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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 30 minutes prior to bleomycin. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for
peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 7 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to bleomycin.
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
Treatment Medications
bleomycin (BLENOXANE) 18 units in sodium chloride 0.9 % 100 mL bag
18 units (rounded from 17.9 units = 10 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 15 minutes. Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency
Medications.
vinCRIStine (ONCOVIN) 2.5 mg in sodium chloride 0.9 % 25 mL bag
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 8 of 39
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
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/12/2016 through 1/1/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/12/2016
Treatment Plan Information
Reference Information (1)
HODGKIN'S LYMPHOMA: Diehl V, et al. N Eng J Med 2003;348(24):2386-95.
Reference Information (2)
HODGKIN'S LYMPHOMA: Engert A, et al. J Clin Oncol 2009;27(27):4548-54.
Reference Information (3)
HODGKIN'S LYMPHOMA: Skoetz N, et al. Lancet Oncol 2013;14(10):943-52.
Reference Information (4)
HODGKIN'S LYMPHOMA: Engert A, et al. Lancet 2012;379(9828):1791-9.
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 9 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Total Bilirubin greater than ULN or
Creatinine Clearance less than 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Patient Instructions(2)
RN to instruct patient regarding food interactions with procarbazine.
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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 63 mg
63 mg (rounded from 62.65 mg = 35 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 2,148 mg in sodium chloride 0.9 % 250 mL bag
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 10 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

2,148 mg (1,200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
procarbazine (MATULANE) cap 200 mg
200 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Use patient's own supply.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Take Home Medications
procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily at bedtime. Take on Days 1 through 7 of Cycle., 200 mg (rounded from 179 mg = 100
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY (HS) starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 10 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 70 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 20 MG tab
Take 3.5 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 70 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 50 MG tab
Take 1.5 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 75 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for etoposide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for etoposide for 120 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT for bleomycin and vinCRIStine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, AST, ALT, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide, and
etoposide for 240 minutes.
Day 2, Cycle 2 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
IV Access
Insert and Maintain Peripheral IV
100 mg/m2 (179 mg) cannot be administered using available products.
The nearest available dose is 200 mg (112 mg/m2).
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 11 of 39
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 prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken procarbazine 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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 2 – Planned for 12/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 12 of 39
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 prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken procarbazine 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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 13 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
Treatment Conditions
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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 30 minutes prior to bleomycin. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for
peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to bleomycin.
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
Treatment Medications
bleomycin (BLENOXANE) 18 units in sodium chloride 0.9 % 100 mL bag
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 14 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

18 units (rounded from 17.9 units = 10 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 15 minutes. Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency
Medications.
vinCRIStine (ONCOVIN) 2.5 mg in sodium chloride 0.9 % 25 mL bag
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/2/2017 through 1/22/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 1/2/2017
Treatment Plan Information
Reference Information (1)
HODGKIN'S LYMPHOMA: Diehl V, et al. N Eng J Med 2003;348(24):2386-95.
Reference Information (2)
HODGKIN'S LYMPHOMA: Engert A, et al. J Clin Oncol 2009;27(27):4548-54.
Reference Information (3)
HODGKIN'S LYMPHOMA: Skoetz N, et al. Lancet Oncol 2013;14(10):943-52.
Reference Information (4)
HODGKIN'S LYMPHOMA: Engert A, et al. Lancet 2012;379(9828):1791-9.
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 15 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Total Bilirubin greater than ULN or
Creatinine Clearance less than 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Patient Instructions(2)
RN to instruct patient regarding food interactions with procarbazine.
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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 63 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 16 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

63 mg (rounded from 62.65 mg = 35 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 2,148 mg in sodium chloride 0.9 % 250 mL bag
2,148 mg (1,200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
procarbazine (MATULANE) cap 200 mg
200 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Use patient's own supply.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Take Home Medications
procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily at bedtime. Take on Days 1 through 7 of Cycle., 200 mg (rounded from 179 mg = 100
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY (HS) starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 10 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 70 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 20 MG tab
Take 3.5 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 70 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 50 MG tab
Take 1.5 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 75 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for etoposide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for etoposide for 120 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT for bleomycin and vinCRIStine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, AST, ALT, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide, and
etoposide for 240 minutes.
Day 2, Cycle 3 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
100 mg/m2 (179 mg) cannot be administered using available products.
The nearest available dose is 200 mg (112 mg/m2).
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 17 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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 prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken procarbazine 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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 3 – Planned for 1/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 18 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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 prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken procarbazine 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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 3 – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 19 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
Treatment Conditions
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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 30 minutes prior to bleomycin. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for
peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to bleomycin.
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 20 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bleomycin (BLENOXANE) 18 units in sodium chloride 0.9 % 100 mL bag
18 units (rounded from 17.9 units = 10 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 15 minutes. Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency
Medications.
vinCRIStine (ONCOVIN) 2.5 mg in sodium chloride 0.9 % 25 mL bag
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 1/23/2017 through 2/12/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/23/2017
Treatment Plan Information
Reference Information (1)
HODGKIN'S LYMPHOMA: Diehl V, et al. N Eng J Med 2003;348(24):2386-95.
Reference Information (2)
HODGKIN'S LYMPHOMA: Engert A, et al. J Clin Oncol 2009;27(27):4548-54.
Reference Information (3)
HODGKIN'S LYMPHOMA: Skoetz N, et al. Lancet Oncol 2013;14(10):943-52.
Reference Information (4)
HODGKIN'S LYMPHOMA: Engert A, et al. Lancet 2012;379(9828):1791-9.
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 21 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Total Bilirubin greater than ULN or
Creatinine Clearance less than 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Patient Instructions(2)
RN to instruct patient regarding food interactions with procarbazine.
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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 22 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1
dose Starting when released
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 63 mg
63 mg (rounded from 62.65 mg = 35 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 2,148 mg in sodium chloride 0.9 % 250 mL bag
2,148 mg (1,200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
procarbazine (MATULANE) cap 200 mg
200 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Use patient's own supply.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Take Home Medications
procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily at bedtime. Take on Days 1 through 7 of Cycle., 200 mg (rounded from 179 mg = 100
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY (HS) starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 10 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 70 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 20 MG tab
Take 3.5 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 70 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 50 MG tab
Take 1.5 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 75 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for etoposide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for etoposide for 120 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT for bleomycin and vinCRIStine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, AST, ALT, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide, and
etoposide for 240 minutes.
Day 2, Cycle 4 – Planned for 1/24/2017
Treatment Plan Information
100 mg/m2 (179 mg) cannot be administered using available products.
The nearest available dose is 200 mg (112 mg/m2).
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 23 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1
through 14, doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV
Days 1, 2 and 3, procarbazine 100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day
8, vinCRIStine 1.4 mg/m2 (maximum dose = 2 mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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 prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken procarbazine 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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 – Planned for 1/25/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 24 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1
through 14, doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV
Days 1, 2 and 3, procarbazine 100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day
8, vinCRIStine 1.4 mg/m2 (maximum dose = 2 mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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 prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken procarbazine 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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 4 – Planned for 1/30/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 25 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1
through 14, doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV
Days 1, 2 and 3, procarbazine 100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day
8, vinCRIStine 1.4 mg/m2 (maximum dose = 2 mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
Treatment Conditions
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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 30 minutes prior to bleomycin. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for
peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to bleomycin.
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 26 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
bleomycin (BLENOXANE) 18 units in sodium chloride 0.9 % 100 mL bag
18 units (rounded from 17.9 units = 10 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 15 minutes. Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency
Medications.
vinCRIStine (ONCOVIN) 2.5 mg in sodium chloride 0.9 % 25 mL bag
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 2/13/2017 through 3/5/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 2/13/2017
Treatment Plan Information
Reference Information (1)
HODGKIN'S LYMPHOMA: Diehl V, et al. N Eng J Med 2003;348(24):2386-95.
Reference Information (2)
HODGKIN'S LYMPHOMA: Engert A, et al. J Clin Oncol 2009;27(27):4548-54.
Reference Information (3)
HODGKIN'S LYMPHOMA: Skoetz N, et al. Lancet Oncol 2013;14(10):943-52.
Reference Information (4)
HODGKIN'S LYMPHOMA: Engert A, et al. Lancet 2012;379(9828):1791-9.
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 27 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Total Bilirubin greater than ULN or
Creatinine Clearance less than 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Patient Instructions(2)
RN to instruct patient regarding food interactions with procarbazine.
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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 28 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 63 mg
63 mg (rounded from 62.65 mg = 35 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 2,148 mg in sodium chloride 0.9 % 250 mL bag
2,148 mg (1,200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
procarbazine (MATULANE) cap 200 mg
200 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Use patient's own supply.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Take Home Medications
procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily at bedtime. Take on Days 1 through 7 of Cycle., 200 mg (rounded from 179 mg = 100
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY (HS) starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 10 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 70 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 20 MG tab
Take 3.5 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 70 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 50 MG tab
Take 1.5 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 75 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for etoposide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for etoposide for 120 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT for bleomycin and vinCRIStine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, AST, ALT, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide, and
etoposide for 240 minutes.
100 mg/m2 (179 mg) cannot be administered using available products.
The nearest available dose is 200 mg (112 mg/m2).
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 29 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 2, Cycle 5 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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 prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken procarbazine 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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 30 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 3, Cycle 5 – Planned for 2/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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 prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken procarbazine 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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 31 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 8, Cycle 5 – Planned for 2/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
Treatment Conditions
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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 30 minutes prior to bleomycin. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for
peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to bleomycin.
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 32 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Treatment Medications
bleomycin (BLENOXANE) 18 units in sodium chloride 0.9 % 100 mL bag
18 units (rounded from 17.9 units = 10 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 15 minutes. Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency
Medications.
vinCRIStine (ONCOVIN) 2.5 mg in sodium chloride 0.9 % 25 mL bag
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 3/6/2017 through 3/26/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 3/6/2017
Treatment Plan Information
Reference Information (1)
HODGKIN'S LYMPHOMA: Diehl V, et al. N Eng J Med 2003;348(24):2386-95.
Reference Information (2)
HODGKIN'S LYMPHOMA: Engert A, et al. J Clin Oncol 2009;27(27):4548-54.
Reference Information (3)
HODGKIN'S LYMPHOMA: Skoetz N, et al. Lancet Oncol 2013;14(10):943-52.
Reference Information (4)
HODGKIN'S LYMPHOMA: Engert A, et al. Lancet 2012;379(9828):1791-9.
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 33 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Total Bilirubin greater than ULN or
Creatinine Clearance less than 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Patient Instructions(2)
RN to instruct patient regarding food interactions with procarbazine.
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 34 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
prednisone (DELTASONE) tab 71.5 mg
71.5 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 63 mg
63 mg (rounded from 62.65 mg = 35 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 2,148 mg in sodium chloride 0.9 % 250 mL bag
2,148 mg (1,200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
procarbazine (MATULANE) cap 200 mg
200 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Use patient's own supply.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Take Home Medications
procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily at bedtime. Take on Days 1 through 7 of Cycle., 200 mg (rounded from 179 mg = 100
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY (HS) starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 10 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 70 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 20 MG tab
Take 3.5 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 70 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 50 MG tab
Take 1.5 tabs by mouth one time daily. Take on Days 1 through 14 of Cycle., 75 mg (rounded from 71.6 mg = 40 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for etoposide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for etoposide for 120 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT for bleomycin and vinCRIStine for 60 minutes.
100 mg/m2 (179 mg) cannot be administered using available products.
The nearest available dose is 200 mg (112 mg/m2).
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 35 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes,
Glucose, BUN, Creatinine, Calcium, AST, ALT, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
doxorubicin, cyclophosphamide, and etoposide for 240 minutes.
Day 2, Cycle 6 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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 prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken procarbazine 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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 36 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 6 – Planned for 3/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
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 prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken procarbazine 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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 358 mg in sodium chloride 0.9 % 1,000 mL NSS bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 37 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 6 – Planned for 3/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin's Lymphoma (Advanced); THERAPY: prednisone 40 mg/m2 by mouth once daily Days 1 through 14,
doxorubicin 35 mg/m2 IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1, etoposide 200 mg/m2 IV Days 1, 2 and 3, procarbazine
100 mg/m2 by mouth once daily on Days 1 through 7, bleomycin 10 units/m2 IV Day 8, vinCRIStine 1.4 mg/m2 (maximum dose = 2
mg) IV Day 8; CYCLE LENGTH: 21 days; COURSE: up to 6 cycles.
Note: This plan only to be used in patients with an IPI score greater than or equal to 4.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
Treatment Conditions
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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 30 minutes prior to bleomycin. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for
peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to bleomycin.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 38 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Treatment Medications
bleomycin (BLENOXANE) 18 units in sodium chloride 0.9 % 100 mL bag
18 units (rounded from 17.9 units = 10 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 15 minutes. Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency
Medications.
vinCRIStine (ONCOVIN) 2.5 mg in sodium chloride 0.9 % 25 mL bag
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone and procarbazine dispensed on
Day 1 of each Cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:59:56 PM Page 39 of 39
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org