/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-96852-en.cckm

201611320

page

100

UWHC,UWMF,

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

CSC HEM Bleomycin Dacarbazine Doxorubicin Vinblastine(28D:1,15) VER 10-3-16 (HL 1031)

CSC HEM Bleomycin Dacarbazine Doxorubicin Vinblastine(28D:1,15) VER 10-3-16 (HL 1031) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM BLEOMYCIN/DACARBAZINE/DOXORUBICIN/VINBLASTINE(28D:1,15) VER: 10-3-16 – Properties
Pre-Cycle – 11/8/2016 through 11/14/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/8/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
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
Take Home Medications
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
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following chemotherapy., 80 mg, Disp-4 cap, R-7, 1 X DAILY starting S
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy., 8 mg, Disp-24 tab, R-5, 1 X DAILY starting S
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
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
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
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
Cycle 1 – 11/15/2016 through 12/12/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/15/2016
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 1 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
HODGKIN LYMPHOMA: Bonadonna G, et al. Cancer 1975;36:252-9.
Reference Information (2)
HODGKIN LYMPHOMA: Santoro A, et al. J Clin Oncol 1987;5:27-37.
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 75K/µL or Total Bilirubin greater than ULN or Creatinine
Clearance less than 50 mL/min.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 2 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine,
dacarbazine for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine, dacarbazine for 150 minutes.
Day 15, Cycle 1 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 3 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if
neutropenic as long as no signs of active infection and patient is monitored closely for signs/symptoms of bleomycin
pulmonary toxicity
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 75K/µL.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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]
11/15/2016 3:32:57 PM Page 4 of 31
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/13/2016 through 1/9/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 5 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
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 Platelets less than or equal to 75K/µL or Total Bilirubin greater than ULN or Creatinine
Clearance less than 50 mL/min.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 6 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine,
dacarbazine for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine, dacarbazine for 150 minutes.
Day 15, Cycle 2 – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 7 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 75K/µL.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 8 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/10/2017 through 2/6/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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
CREATININE
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 9 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold and notify authorizing prescriber for Platelets less than or equal to 75K/µL or Total Bilirubin greater than ULN or Creatinine
Clearance less than 50 mL/min.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 10 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine,
dacarbazine for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine, dacarbazine for 150 minutes.
Day 15, Cycle 3 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 75K/µL.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 11 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 12 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 2/7/2017 through 3/6/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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
CREATININE
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 Platelets less than or equal to 75K/µL or Total Bilirubin greater than ULN or Creatinine
Clearance less than 50 mL/min.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 13 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 14 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine,
dacarbazine for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine, dacarbazine for 150 minutes.
Day 15, Cycle 4 – Planned for 2/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 75K/µL.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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 10 UNIT/ML lock flush 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]
11/15/2016 3:32:57 PM Page 15 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 3/7/2017 through 4/3/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 16 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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
CREATININE
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 Platelets less than or equal to 75K/µL or Total Bilirubin greater than ULN or Creatinine
Clearance less than 50 mL/min.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 17 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine,
dacarbazine for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine, dacarbazine for 150 minutes.
Day 15, Cycle 5 – Planned for 3/21/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 18 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 75K/µL.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 19 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 4/4/2017 through 5/1/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 20 of 31
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
CREATININE
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 Platelets less than or equal to 75K/µL or Total Bilirubin greater than ULN or Creatinine
Clearance less than 50 mL/min.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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]
11/15/2016 3:32:57 PM Page 21 of 31
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine,
dacarbazine for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine, dacarbazine for 150 minutes.
Day 15, Cycle 6 – Planned for 4/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 22 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 75K/µL.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 23 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 5/2/2017 through 5/29/2017 (28 days), Planned
Day 1, Cycle 7 – Planned for 5/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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
CREATININE
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.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 24 of 31
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 Platelets less than or equal to 75K/µL or Total Bilirubin greater than ULN
or Creatinine Clearance less than 50 mL/min.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 25 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine,
dacarbazine for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine, dacarbazine for 150 minutes.
Day 15, Cycle 7 – Planned for 5/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 75K/µL.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 26 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 27 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 5/30/2017 through 6/26/2017 (28 days), Planned
Day 1, Cycle 8 – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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
CREATININE
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 Platelets less than or equal to 75K/µL or Total Bilirubin greater than ULN or Creatinine
Clearance less than 50 mL/min.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 28 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush 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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 29 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine,
dacarbazine for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, bleomycin, vinBLAStine, dacarbazine for 150 minutes.
Day 15, Cycle 8 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: doxorubicin 25 mg/m2 IV Days 1 and 15, vinBLAStine 6mg/m2 IV Days 1 and 15,
bleomycin 10 units/m2 IV Days 1 and 15, dacarbazine 375 mg/m2 IV Days 1 and 15; CYCLE LENGTH: 28 days; COURSE: 4 to 8
cycles.
Note to All Staff (1)
Avoid filgrastim because of potential synergistic risk with bleomycin for lung toxicity. Ok to use filgrastim if neutropenic as long as no
signs of active infection and patient is monitored closely for signs/symptoms of bleomycin pulmonary toxicity
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal to 75K/µL.
Treatment Parameters (2)
Notify (do NOT hold) authorizing prescriber for ANC less than or equal to 1,000/µL.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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ZZtestonc,Andrew [2428787]
11/15/2016 3:32:57 PM Page 30 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 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.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
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
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
dacarbazine (DTIC-DOME) 671 mg in sodium chloride 0.9 % 250 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
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]
11/15/2016 3:32:57 PM Page 31 of 31
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org