/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-96860-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 Doxorubicin Etoposide(Oral) Prednisone Vincristine VER 10-3-16 (HL 4302)

CSC HEM Cyclophosphamide Doxorubicin Etoposide(Oral) Prednisone Vincristine VER 10-3-16 (HL 4302) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM CYCLOPHOSPHAMIDE/DOXORUBICIN/ETOPOSIDE(ORAL)/PREDNISONE/VINCRISTINE 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: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following chemotherapy., 80 mg, Disp-2 cap, R-7, 1 X DAILY starting S, Local
Printer
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-7, 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
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
Take Home Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth one time daily. Take on Days 1 through 7., 300 mg, R-0, 1 X DAILY 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: Schmitz N, et al. Blood 2010;116:3418-25.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:59:28 PM Page 1 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (2)
LYMPHOMA: Ellin F, et al. Blood 2014;124(10):1570-77.
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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 and resulted: WBC, ANC, Platelets, BUN, Creatinine, 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 or Creatinine Clearance less than or equal to 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 179 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 1:59:28 PM Page 2 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
90 mg (rounded from 89.5 mg = 50 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
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) 1,342.6 mg in sodium chloride 0.9 % 250 mL bag
1,342.6 mg (rounded from 1,342.5 mg = 750 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
etoposide (VEPESID) 179 mg in sodium chloride 0.9 % 500 mL NSS bag
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of Cycle 1) and
oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 9 tabs by mouth one time daily. Take on Days 2 through 5., 180 mg (rounded from 179 mg = 100 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-7, 1 X DAILY starting S, Local Printer
Patient received Day 1 dose as premedication in clinic
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 179 mg = 100 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC, ANC (DIFF if done locally), Total Bilirubin,
BUN Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, vinCRIStine, cyclophosphamide, etoposide for 180
minutes.
Lab Only - Day 10, Cycle 1 – Planned for 11/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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
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 1:59:28 PM Page 3 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/12/2016 through 1/1/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, BUN, Creatinine, 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 or Creatinine Clearance less than or equal to 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/21/2016 1:59:28 PM Page 4 of 20
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 179 mg
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
90 mg (rounded from 89.5 mg = 50 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
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) 1,342.6 mg in sodium chloride 0.9 % 250 mL bag
1,342.6 mg (rounded from 1,342.5 mg = 750 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
etoposide (VEPESID) 179 mg in sodium chloride 0.9 % 500 mL NSS bag
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of Cycle 1) and
oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 179 mg = 100 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
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 1:59:28 PM Page 5 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC, ANC (DIFF if done locally), Total Bilirubin,
BUN Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, vinCRIStine, cyclophosphamide, etoposide for 180
minutes.
Lab Only - Day 10, Cycle 2 – Planned for 12/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/2/2017 through 1/22/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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
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ZZtestonc,Andrew [2428787]
11/21/2016 1:59:28 PM Page 6 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, BUN, Creatinine, 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 or Creatinine Clearance less than or equal to 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 179 mg
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
90 mg (rounded from 89.5 mg = 50 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
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) 1,342.6 mg in sodium chloride 0.9 % 250 mL bag
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ZZtestonc,Andrew [2428787]
11/21/2016 1:59:28 PM Page 7 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1,342.6 mg (rounded from 1,342.5 mg = 750 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
etoposide (VEPESID) 179 mg in sodium chloride 0.9 % 500 mL NSS bag
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of Cycle 1) and
oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 179 mg = 100 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC, ANC (DIFF if done locally), Total Bilirubin,
BUN Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, vinCRIStine, cyclophosphamide, etoposide for 180
minutes.
Lab Only - Day 10, Cycle 3 – Planned for 1/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 1/23/2017 through 2/12/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/23/2017
Treatment Plan Information
Treatment Plan Summary
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 1:59:28 PM Page 8 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, BUN, Creatinine, 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 or Creatinine Clearance less than or equal to 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/21/2016 1:59:28 PM Page 9 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 179 mg
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
90 mg (rounded from 89.5 mg = 50 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
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) 1,342.6 mg in sodium chloride 0.9 % 250 mL bag
1,342.6 mg (rounded from 1,342.5 mg = 750 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
etoposide (VEPESID) 179 mg in sodium chloride 0.9 % 500 mL NSS bag
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of Cycle 1) and
oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 179 mg = 100 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC, ANC (DIFF if done locally), Total Bilirubin,
BUN Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, vinCRIStine, cyclophosphamide, etoposide for 180
minutes.
Lab Only - Day 10, Cycle 4 – Planned for 2/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
IV Access
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 1:59:28 PM Page 10 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 2/13/2017 through 3/5/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 2/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, BUN, Creatinine, 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 or Creatinine Clearance less than or equal to 50 mL/min.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/21/2016 1:59:28 PM Page 11 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 179 mg
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
90 mg (rounded from 89.5 mg = 50 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
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) 1,342.6 mg in sodium chloride 0.9 % 250 mL bag
1,342.6 mg (rounded from 1,342.5 mg = 750 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
etoposide (VEPESID) 179 mg in sodium chloride 0.9 % 500 mL NSS bag
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of Cycle 1) and
oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 179 mg = 100 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
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ZZtestonc,Andrew [2428787]
11/21/2016 1:59:28 PM Page 12 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC, ANC (DIFF if done locally), Total Bilirubin,
BUN Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, vinCRIStine, cyclophosphamide, etoposide for 180
minutes.
Lab Only - Day 10, Cycle 5 – Planned for 2/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 3/6/2017 through 3/26/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 3/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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.
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 1:59:28 PM Page 13 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, BUN, Creatinine, 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 or Creatinine Clearance less than or equal to 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 179 mg
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 1:59:28 PM Page 14 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

90 mg (rounded from 89.5 mg = 50 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
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) 1,342.6 mg in sodium chloride 0.9 % 250 mL bag
1,342.6 mg (rounded from 1,342.5 mg = 750 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
etoposide (VEPESID) 179 mg in sodium chloride 0.9 % 500 mL NSS bag
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of Cycle 1) and
oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 179 mg = 100 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC, ANC (DIFF if done locally), Total Bilirubin,
BUN Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, vinCRIStine, cyclophosphamide, etoposide for 180
minutes.
Lab Only - Day 10, Cycle 6 – Planned for 3/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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 1:59:28 PM Page 15 of 20
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
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, BUN, Creatinine, 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 or Creatinine Clearance less than or equal to 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:59:28 PM Page 16 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 179 mg
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
90 mg (rounded from 89.5 mg = 50 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
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) 1,342.6 mg in sodium chloride 0.9 % 250 mL bag
1,342.6 mg (rounded from 1,342.5 mg = 750 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
etoposide (VEPESID) 179 mg in sodium chloride 0.9 % 500 mL NSS bag
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of Cycle 1) and
oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 179 mg = 100 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC, ANC (DIFF if done locally), Total Bilirubin,
BUN Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, vinCRIStine, cyclophosphamide, etoposide for 180
minutes.
Lab Only - Day 10, Cycle 7 – Planned for 4/5/2017
Treatment Plan Information
Treatment Plan Summary
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 1:59:28 PM Page 17 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 4/17/2017 through 5/7/2017 (21 days), Planned
Day 1, Cycle 8 – Planned for 4/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/21/2016 1:59:28 PM Page 18 of 20
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 and resulted: WBC, ANC, Platelets, BUN, Creatinine, 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 or Creatinine Clearance less than or equal to 50 mL/min.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 179 mg
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
90 mg (rounded from 89.5 mg = 50 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
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) 1,342.6 mg in sodium chloride 0.9 % 250 mL bag
1,342.6 mg (rounded from 1,342.5 mg = 750 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
etoposide (VEPESID) 179 mg in sodium chloride 0.9 % 500 mL NSS bag
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
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ZZtestonc,Andrew [2428787]
11/21/2016 1:59:28 PM Page 19 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of Cycle 1) and
oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 179 mg = 100 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC, ANC (DIFF if done locally), Total Bilirubin,
BUN Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, vinCRIStine, cyclophosphamide, etoposide for 180
minutes.
Lab Only - Day 10, Cycle 8 – Planned for 4/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: prednisone 100 mg/m2 by mouth Day 1, 2, 3, 4, 5, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine
2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, etoposide 100 mg/m2 by mouth twice daily
Days 2 and 3, CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is NOT preferred for T-cell and NK-cell lymphoma patients greater than 60 years of age.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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 1:59:28 PM Page 20 of 20
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org