/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-96851-en.cckm

201710282

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UWHC,UWMF,

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

CSC Hem Bendamustine (21D:1,2) For NHL Ver 10-9-17 (HL 3144)

CSC Hem Bendamustine (21D:1,2) For NHL Ver 10-9-17 (HL 3144) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM NHL BENDAMUSTINE(21D:1,2) VER: 10-09-17 –  Properties
Pre-Cycle –  10/2/2017 through 10/8/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 10/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
POTASSIUM
Expected: S Approximate, Expires: S+365, Routine
URIC ACID
Expected: S Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Normal, Routine
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
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
acyclovir (ZOVIRAX) 400 MG tab
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 1 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 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
famotidine (PEPCID) 20 MG tab
Take 1 tab by mouth 2 times daily., 20 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
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 ***. Continue until ANC is greater than *** after
nadir., 300 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
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 ***. Continue until ANC is greater than *** after
nadir., 480 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 –  10/9/2017 through 10/29/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 10/9/2017
Treatment Plan Information
Reference Information (1)
NON HODGKIN LYMPHOMA: Kahl BS, et al. Cancer 2009 Nov 4.(Epub ahead of print)
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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, ANC, Creatinine, Potassium, Uric Acid, LDH, AST, ALT and Total
Bilirubin.
Treatment Parameters
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 2 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 3 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 1 –  Planned for 10/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 4 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 1 –  Planned for 10/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 5 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  10/30/2017 through 11/19/2017 (21 days), Planned
Day 1, Cycle 2 –  Planned for 10/30/2017
Treatment Plan Information
Reference Information (1)
NON HODGKIN LYMPHOMA: Kahl BS, et al. Cancer 2009 Nov 4.(Epub ahead of print)
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+20 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+20 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+20 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 6 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 7 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 2 –  Planned for 10/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 8 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 2 –  Planned for 11/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 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 3 –  11/20/2017 through 12/10/2017 (21 days), Planned
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 9 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Day 1, Cycle 3 –  Planned for 11/20/2017
Treatment Plan Information
Reference Information (1)
NON HODGKIN LYMPHOMA: Kahl BS, et al. Cancer 2009 Nov 4.(Epub ahead of print)
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+20 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+20 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+20 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 10 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be
treated in a location to optimize emergency care. 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 11 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 3 –  Planned for 11/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 12 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 3 –  Planned for 11/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 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 4 –  12/11/2017 through 12/31/2017 (21 days), Planned
Day 1, Cycle 4 –  Planned for 12/11/2017
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 13 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
NON HODGKIN LYMPHOMA: Kahl BS, et al. Cancer 2009 Nov 4.(Epub ahead of print)
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+20 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+20 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+20 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 14 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 15 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Day 2, Cycle 4 –  Planned for 12/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 16 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 4 –  Planned for 12/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 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 5 –  1/1/2018 through 1/21/2018 (21 days), Planned
Day 1, Cycle 5 –  Planned for 1/1/2018
Treatment Plan Information
Reference Information (1)
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 17 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

NON HODGKIN LYMPHOMA: Kahl BS, et al. Cancer 2009 Nov 4.(Epub ahead of print)
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+20 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+20 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+20 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 18 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 5 –  Planned for 1/2/2018
Treatment Plan Information
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 19 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 20 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 5 –  Planned for 1/10/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 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 6 –  1/22/2018 through 2/11/2018 (21 days), Planned
Day 1, Cycle 6 –  Planned for 1/22/2018
Treatment Plan Information
Reference Information (1)
NON HODGKIN LYMPHOMA: Kahl BS, et al. Cancer 2009 Nov 4.(Epub ahead of print)
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 21 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+20 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+20 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+20 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 22 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 6 –  Planned for 1/23/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 23 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 24 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 6 –  Planned for 1/31/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 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 7 –  2/12/2018 through 3/4/2018 (21 days), Planned
Day 1, Cycle 7 –  Planned for 2/12/2018
Treatment Plan Information
Reference Information (1)
NON HODGKIN LYMPHOMA: Kahl BS, et al. Cancer 2009 Nov 4.(Epub ahead of print)
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 25 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+20 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+20 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+20 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 26 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 7 –  Planned for 2/13/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 27 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 28 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 7 –  Planned for 2/21/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 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 8 –  3/5/2018 through 3/25/2018 (21 days), Planned
Day 1, Cycle 8 –  Planned for 3/5/2018
Treatment Plan Information
Reference Information (1)
NON HODGKIN LYMPHOMA: Kahl BS, et al. Cancer 2009 Nov 4.(Epub ahead of print)
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Consent
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 29 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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 WITHOUT DIFFERENTIAL
Expected: S+20 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+20 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+20 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 30 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 8 –  Planned for 3/6/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 31 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 120 mg/m2 in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 32 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

120 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 8 –  Planned for 3/14/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: bendamustine 120 mg/m2 IV Day 1 and 2; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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 WITHOUT DIFFERENTIAL
Expected: S+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Edward E [2435061]
10/9/2017 9:20:05 AM Page 33 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org