/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-96855-en.cckm

201611326

page

100

UWHC,UWMF,

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

CSC HEM Chlorambucil(28D:1-14) Prednisone(28D:1-14) Procarbazine(28D:1-14) Vinblastine(28D:1,8) VER 10-3-16 (HL 1532)

CSC HEM Chlorambucil(28D:1-14) Prednisone(28D:1-14) Procarbazine(28D:1-14) Vinblastine(28D:1,8) VER 10-3-16 (HL 1532) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM CHLORAMBUCIL(28D:1-14)/PREDNISONE(28D:1-14)/PROCARBAZINE(28D:1-14)/VINBLASTINE(28D:1,8) VER: 10-
3-16 – Properties
Pre-Cycle – 11/14/2016 through 11/20/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
acyclovir (ZOVIRAX) 400 MG tab
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
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
Cycle 1 – 11/21/2016 through 12/18/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
LYMPHOMA: Capra M, et al. Eur J of Cancer 2007;43:1171-1179.
Reference Information (2)
LYMPHOMA: McElwain T J, et al. Br J Cancer 1977;36:276-280.
Reference Information (3)
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 1 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

LYMPHOMA: The International ChlVPP Treatment Group. Ann Oncol 1995;6(2):167-72.
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Total
Bilirubin greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): chlorambucil, procarbazine.(dispensed D1
each cycle) and prednisone (dispensed Cycle 1 Day 1).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take 5.5 tabs by mouth one time daily. Take on Day 1 through Day 14., 11 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Maximum dose = 10 mg/day.
procarbazine (MATULANE) 50 MG cap
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 2 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take 4 caps by mouth one time daily. Take on Day 1 through Day 14., 200 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
prednisone (DELTASONE) 20 MG tab
Take 2 tabs by mouth one time daily. Take on Day 1 through Day 14., 40 mg, Disp-28 tab, R-9, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinBLAStine for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointment(s) have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC,
Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT for vinBLAStine 30 minutes.
Day 8, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 3 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
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
Maximum dose = 10 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/19/2016 through 1/15/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Total
Bilirubin greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 4 of 26
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): chlorambucil, procarbazine.(dispensed D1
each cycle) and prednisone (dispensed Cycle 1 Day 1).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take 5.5 tabs by mouth one time daily. Take on Day 1 through Day 14., 11 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Maximum dose = 10 mg/day.
procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily. Take on Day 1 through Day 14., 200 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinBLAStine for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointment(s) have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC,
Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT for vinBLAStine 30 minutes.
Day 8, Cycle 2 – Planned for 12/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 5 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/16/2017 through 2/12/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 6 of 26
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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Total
Bilirubin greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): chlorambucil, procarbazine.(dispensed D1
each cycle) and prednisone (dispensed Cycle 1 Day 1).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take 5.5 tabs by mouth one time daily. Take on Day 1 through Day 14., 11 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Maximum dose = 10 mg/day.
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 7 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily. Take on Day 1 through Day 14., 200 mg (rounded from 179 mg = 100
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinBLAStine for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointment(s) have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC,
Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT for vinBLAStine 30 minutes.
Day 8, Cycle 3 – Planned for 1/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 8 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Maximum dose = 10 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 2/13/2017 through 3/12/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Total
Bilirubin greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 9 of 26
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): chlorambucil, procarbazine.(dispensed D1
each cycle) and prednisone (dispensed Cycle 1 Day 1).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take 5.5 tabs by mouth one time daily. Take on Day 1 through Day 14., 11 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Maximum dose = 10 mg/day.
procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily. Take on Day 1 through Day 14., 200 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinBLAStine for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointment(s) have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC,
Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT for vinBLAStine 30 minutes.
Day 8, Cycle 4 – Planned for 2/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 10 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 3/13/2017 through 4/9/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 11 of 26
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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Total
Bilirubin greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): chlorambucil, procarbazine.(dispensed D1
each cycle) and prednisone (dispensed Cycle 1 Day 1).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take 5.5 tabs by mouth one time daily. Take on Day 1 through Day 14., 11 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Maximum dose = 10 mg/day.
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 12 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily. Take on Day 1 through Day 14., 200 mg (rounded from 179 mg = 100
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinBLAStine for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointment(s) have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC,
Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT for vinBLAStine 30 minutes.
Day 8, Cycle 5 – Planned for 3/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 13 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Maximum dose = 10 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 4/10/2017 through 5/7/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Total
Bilirubin greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 14 of 26
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): chlorambucil, procarbazine.(dispensed D1
each cycle) and prednisone (dispensed Cycle 1 Day 1).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take 5.5 tabs by mouth one time daily. Take on Day 1 through Day 14., 11 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Maximum dose = 10 mg/day.
procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily. Take on Day 1 through Day 14., 200 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinBLAStine for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointment(s) have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC,
Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT for vinBLAStine 30 minutes.
Day 8, Cycle 6 – Planned for 4/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 15 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 5/8/2017 through 6/4/2017 (28 days), Planned
Day 1, Cycle 7 – Planned for 5/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 16 of 26
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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Total
Bilirubin greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): chlorambucil, procarbazine.(dispensed D1
each cycle) and prednisone (dispensed Cycle 1 Day 1).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take 5.5 tabs by mouth one time daily. Take on Day 1 through Day 14., 11 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Maximum dose = 10 mg/day.
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 17 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily. Take on Day 1 through Day 14., 200 mg (rounded from 179 mg = 100
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinBLAStine for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointment(s) have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC,
Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT for vinBLAStine 30 minutes.
Day 8, Cycle 7 – Planned for 5/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 18 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Maximum dose = 10 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 6/5/2017 through 7/2/2017 (28 days), Planned
Day 1, Cycle 8 – Planned for 6/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Total
Bilirubin greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 19 of 26
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): chlorambucil, procarbazine.(dispensed D1
each cycle) and prednisone (dispensed Cycle 1 Day 1).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take 5.5 tabs by mouth one time daily. Take on Day 1 through Day 14., 11 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Maximum dose = 10 mg/day.
procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily. Take on Day 1 through Day 14., 200 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinBLAStine for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointment(s) have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC,
Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT for vinBLAStine 30 minutes.
Day 8, Cycle 8 – Planned for 6/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 20 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 9 – 7/3/2017 through 7/30/2017 (28 days), Planned
Day 1, Cycle 9 – Planned for 7/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 21 of 26
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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Total
Bilirubin greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): chlorambucil, procarbazine.(dispensed D1
each cycle) and prednisone (dispensed Cycle 1 Day 1).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take 5.5 tabs by mouth one time daily. Take on Day 1 through Day 14., 11 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Maximum dose = 10 mg/day.
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 22 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily. Take on Day 1 through Day 14., 200 mg (rounded from 179 mg = 100
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinBLAStine for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointment(s) have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC,
Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT for vinBLAStine 30 minutes.
Day 8, Cycle 9 – Planned for 7/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 23 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Maximum dose = 10 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 10 – 7/31/2017 through 8/27/2017 (28 days), Planned
Day 1, Cycle 10 – Planned for 7/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Total
Bilirubin greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 24 of 26
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): chlorambucil, procarbazine.(dispensed D1
each cycle) and prednisone (dispensed Cycle 1 Day 1).
Take Home Medications
chlorambucil (LEUKERAN) 2 MG tab
Take 5.5 tabs by mouth one time daily. Take on Day 1 through Day 14., 11 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Maximum dose = 10 mg/day.
procarbazine (MATULANE) 50 MG cap
Take 4 caps by mouth one time daily. Take on Day 1 through Day 14., 200 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinBLAStine for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointment(s) have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC,
Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT for vinBLAStine 30 minutes.
Day 8, Cycle 10 – Planned for 8/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: vinBLAStine 6 mg/m2 (max = 10 mg) IV Day 1 and 8, chlorambucil 6 mg/m2 (maximum
10 mg/day) by mouth once daily Day 1 through 14, procarbazine 100 mg/m2 by mouth once daily Day 1 through 14, prednisone 40
mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 28 days; COURSE: 6 to 10 cycles given until complete remission. After
complete remission, additional 5 cycles are given. Maximum 10 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
100 mg/m2 (179 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 200 mg (112 mg/m2).
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 25 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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
Maximum dose = 10 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Ordered dose of 6 mg/m2 ONCE exceeds the recommended single dose limit of 10 mg.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:25:32 PM Page 26 of 26
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org