/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-96861-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 Vincristine(21D:1) Prednisone(21D:1-5) VER 10-3-16 (HL 1037)

CSC HEM Cyclophosphamide Doxorubicin Vincristine(21D:1) Prednisone(21D:1-5) VER 10-3-16 (HL 1037) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM CYCLOPHOSPHAMIDE/DOXORUBICIN/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: doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV
Day 1, prednisone 100 mg PO Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Preferred regimen in 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
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
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
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-11, 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: Habermann TM, et al. J Clin Oncol 2006;24:3121-7.
Reference Information (2)
LYMPHOMA: Schmitz N, et al. Blood 2010;116(18):3418-25.
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV
Day 1, prednisone 100 mg PO Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
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ZZtestonc,Andrew [2428787]
11/21/2016 2:01:08 PM Page 1 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Preferred regimen in 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: CBC with DIFF, 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
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 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:01:08 PM Page 2 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
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, doxorubicin, 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
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV
Day 1, prednisone 100 mg PO Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Preferred regimen in 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
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:01:08 PM Page 3 of 14
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 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
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, doxorubicin, 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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:01:08 PM Page 4 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
750 mg/m2 IV Day 1, prednisone 100 mg PO Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Preferred regimen in 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
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
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:01:08 PM Page 5 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
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, doxorubicin, 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
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV
Day 1, prednisone 100 mg PO Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Preferred regimen in 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
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/21/2016 2:01:08 PM Page 6 of 14
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, 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
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 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:01:08 PM Page 7 of 14
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 to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide, doxorubicin, 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
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV
Day 1, prednisone 100 mg PO Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Preferred regimen in 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
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
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 2:01:08 PM Page 8 of 14
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
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 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
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, doxorubicin, 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
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV
Day 1, prednisone 100 mg PO Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Preferred regimen in 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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:01:08 PM Page 9 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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
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 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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 2:01:08 PM Page 10 of 14
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.
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, doxorubicin, and vinCRIStine for 90 minutes.
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: doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV
Day 1, prednisone 100 mg PO Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Preferred regimen in 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
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
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:01:08 PM Page 11 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 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 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
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, doxorubicin, 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
Treatment Plan Summary
DISEASE: Lymphoma; THERAPY: doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide 750 mg/m2 IV
Day 1, prednisone 100 mg PO Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Preferred regimen in T-cell and NK-cell lymphoma patients greater than 60 years of age.
Consent
Verify Consent
Verify informed consent has been obtained.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:01:08 PM Page 12 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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
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
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 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 2:01:08 PM Page 13 of 14
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.
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, doxorubicin, and vinCRIStine for 90 minutes.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:01:08 PM Page 14 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org