/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-96859-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 Cyclophosphamide(21D:1) Vincristine(21D:1) Prednisone(21D:1-5) VER 10-3-16 (HL 1043)

CSC HEM Cyclophosphamide(21D:1) Vincristine(21D:1) Prednisone(21D:1-5) VER 10-3-16 (HL 1043) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM CYCLOPHOSPHAMIDE(21D:1)/VINCRISTINE(21D:1)/PREDNISONE(21D:1-5) 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: Lymphoma; THERAPY: vinCRIStine 2 mg IV Day 1, cyclophosphamide 1000 mg/m2 IV Day 1, prednisone 100 mg PO
daily Days 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
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
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
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
Cycle 1 – 11/21/2016 through 12/11/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
LYMPHOMA: J Clin Oncol 2004;ASCO annual meeting proceedings 22(14s):165.
Reference Information (2)
LYMPHOMA: Hagenbeek A, et al. J Clin Oncol 2006;24:1590-9.
Reference Information (3)
LYMPHOMA: Marcus R. Et al. Blood 2005;105:1417-23.
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: vinCRIStine 2 mg IV Day 1, cyclophosphamide 1000 mg/m2 IV Day 1, prednisone 100 mg PO
daily Days 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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ZZtestonc,Andrew [2428787]
11/21/2016 1:58:09 PM Page 1 of 12
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: WBC, ANC, Platelets, 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
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Take Home Medications
prednisone (DELTASONE) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Day 2 through 5., 100 mg, Disp-8 tab, R-8, 1 X DAILY starting S+1
Day 1 dose given as premedication in clinic.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for 90 minutes.
Cycle 2 – 12/12/2016 through 1/1/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/12/2016
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ZZtestonc,Andrew [2428787]
11/21/2016 1:58:09 PM Page 2 of 12
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)
LYMPHOMA: J Clin Oncol 2004;ASCO annual meeting proceedings 22(14s):165.
Reference Information (2)
LYMPHOMA: Hagenbeek A, et al. J Clin Oncol 2006;24:1590-9.
Reference Information (3)
LYMPHOMA: Marcus R. Et al. Blood 2005;105:1417-23.
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: vinCRIStine 2 mg IV Day 1, cyclophosphamide 1000 mg/m2 IV Day 1, prednisone 100 mg PO
daily Days 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 1:58:09 PM Page 3 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for 90 minutes.
Cycle 3 – 1/2/2017 through 1/22/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 1/2/2017
Treatment Plan Information
Reference Information (1)
LYMPHOMA: J Clin Oncol 2004;ASCO annual meeting proceedings 22(14s):165.
Reference Information (2)
LYMPHOMA: Hagenbeek A, et al. J Clin Oncol 2006;24:1590-9.
Reference Information (3)
LYMPHOMA: Marcus R. Et al. Blood 2005;105:1417-23.
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: vinCRIStine 2 mg IV Day 1, cyclophosphamide 1000 mg/m2 IV Day 1, prednisone 100 mg PO
daily Days 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:58:09 PM Page 4 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for 90 minutes.
Cycle 4 – 1/23/2017 through 2/12/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/23/2017
Treatment Plan Information
Reference Information (1)
LYMPHOMA: J Clin Oncol 2004;ASCO annual meeting proceedings 22(14s):165.
Reference Information (2)
LYMPHOMA: Hagenbeek A, et al. J Clin Oncol 2006;24:1590-9.
Reference Information (3)
LYMPHOMA: Marcus R. Et al. Blood 2005;105:1417-23.
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/21/2016 1:58:09 PM Page 5 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Lymphoma; THERAPY: vinCRIStine 2 mg IV Day 1, cyclophosphamide 1000 mg/m2 IV Day 1, prednisone 100 mg PO
daily Days 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 1,790 mg in sodium chloride 0.9 % 250 mL bag
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ZZtestonc,Andrew [2428787]
11/21/2016 1:58:09 PM Page 6 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for 90 minutes.
Cycle 5 – 2/13/2017 through 3/5/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 2/13/2017
Treatment Plan Information
Reference Information (1)
LYMPHOMA: J Clin Oncol 2004;ASCO annual meeting proceedings 22(14s):165.
Reference Information (2)
LYMPHOMA: Hagenbeek A, et al. J Clin Oncol 2006;24:1590-9.
Reference Information (3)
LYMPHOMA: Marcus R. Et al. Blood 2005;105:1417-23.
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: vinCRIStine 2 mg IV Day 1, cyclophosphamide 1000 mg/m2 IV Day 1, prednisone 100 mg PO
daily Days 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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]
11/21/2016 1:58:09 PM Page 7 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for 90 minutes.
Cycle 6 – 3/6/2017 through 3/26/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 3/6/2017
Treatment Plan Information
Reference Information (1)
LYMPHOMA: J Clin Oncol 2004;ASCO annual meeting proceedings 22(14s):165.
Reference Information (2)
LYMPHOMA: Hagenbeek A, et al. J Clin Oncol 2006;24:1590-9.
Reference Information (3)
LYMPHOMA: Marcus R. Et al. Blood 2005;105:1417-23.
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: vinCRIStine 2 mg IV Day 1, cyclophosphamide 1000 mg/m2 IV Day 1, prednisone 100 mg PO
daily Days 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/21/2016 1:58:09 PM Page 8 of 12
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
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
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for 90 minutes.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:58:09 PM Page 9 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 7 – 3/27/2017 through 4/16/2017 (21 days), Planned
Day 1, Cycle 7 – Planned for 3/27/2017
Treatment Plan Information
Reference Information (1)
LYMPHOMA: J Clin Oncol 2004;ASCO annual meeting proceedings 22(14s):165.
Reference Information (2)
LYMPHOMA: Hagenbeek A, et al. J Clin Oncol 2006;24:1590-9.
Reference Information (3)
LYMPHOMA: Marcus R. Et al. Blood 2005;105:1417-23.
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: vinCRIStine 2 mg IV Day 1, cyclophosphamide 1000 mg/m2 IV Day 1, prednisone 100 mg PO
daily Days 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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ZZtestonc,Andrew [2428787]
11/21/2016 1:58:09 PM Page 10 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for 90 minutes.
Cycle 8 – 4/17/2017 through 5/7/2017 (21 days), Planned
Day 1, Cycle 8 – Planned for 4/17/2017
Treatment Plan Information
Reference Information (1)
LYMPHOMA: J Clin Oncol 2004;ASCO annual meeting proceedings 22(14s):165.
Reference Information (2)
LYMPHOMA: Hagenbeek A, et al. J Clin Oncol 2006;24:1590-9.
Reference Information (3)
LYMPHOMA: Marcus R. Et al. Blood 2005;105:1417-23.
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: vinCRIStine 2 mg IV Day 1, cyclophosphamide 1000 mg/m2 IV Day 1, prednisone 100 mg PO
daily Days 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/21/2016 1:58:09 PM Page 11 of 12
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, 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
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for 90 minutes.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:58:09 PM Page 12 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org