/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-96879-en.cckm

201710282

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UWHC,UWMF,

Tools,

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

CSC HEM NHL Bendamustine(28D:1,2) Rituximab(28D:1) VER 10-9-17 (HL 3091)

CSC HEM NHL Bendamustine(28D:1,2) Rituximab(28D:1) VER 10-9-17 (HL 3091) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM NHL BENDAMUSTINE(28D:1,2)/RITUXIMAB (28D:1) VER: 10-09-17 –  Properties
Pre-Cycle –  10/2/2017 through 10/8/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 10/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
POTASSIUM
Expected: S Approximate, Expires: S+365, Routine
URIC ACID
Expected: S Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Normal, Routine
HEPATITIS B CORE AB, TOTAL
Expected: S Approximate, Expires: S+365, Routine
HEPATITIS B SURFACE AG
Expected: S Approximate, Expires: S+365, Routine
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 1 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

HEPATITIS B SURFACE AB
Expected: S Approximate, Expires: S+122, Routine
Pre-Labs (delete all that do not apply)
HEPATITIS B DNA, ULTRA QUANT, PCR
Expected: S Approximate, Expires: S+122, Routine
Draw if Hepatitis B Core AB is positive.
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tablet by mouth twice daily on Saturday and Sunday., Disp-16 tab, R-5, starting S
famotidine (PEPCID) 20 MG tab
Take 1 tab by mouth 2 times daily., 20 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after
nadir., 300 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after
nadir., 480 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 –  10/9/2017 through 11/5/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 10/9/2017
Treatment Plan Information
Reference Information (1)
NON HODGKIN LYMPHOMA: Robinson et al, J Clin Oncol. (2008);26:4473-9.
Reference Information (2)
NON HODGKIN LYMPHOMA: Rummel et al, J Clin Oncol. (2005);23:3383-9.
Reference Information (3)
CD20 POSITIVE LYMPHOMA: McLaughlin P, et al. Oncology 1998;12:1762-9.
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 2 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal
necrolysis (TEN), some fatal, have been reported when bendamustine was administered concomitantly
with allopurinol and other medications known to cause these syndromes. Consider risk versus benefit
of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis at initiation of
treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Potassium, Uric Acid, LDH, AST, ALT and 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 Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion
complete. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension,
stop infusion and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during
which the reaction occurred.
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.
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 3 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 4 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

DAY 29 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT for bendamustine and rituximab for
240 minutes.
Day 2, Cycle 1 –  Planned for 10/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 5 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 1 –  Planned for 10/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 Approximate, Expires: S+365, Routine
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 6 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  11/6/2017 through 12/3/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 11/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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+27 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+27 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+27 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and Total Bilirubin.
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 7 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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 Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN
or ALT greater than 2.5 X ULN or Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion
complete. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension,
stop infusion and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during
which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 8 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT for bendamustine and rituximab for
240 minutes.
Day 2, Cycle 2 –  Planned for 11/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 9 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 10 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10 , Cycle 2 –  Planned for 11/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 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 –  12/4/2017 through 12/31/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 12/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Consent
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 11 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

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+27 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+27 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+27 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and 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 Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion
complete. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension,
stop infusion and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during
which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 12 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 13 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT for bendamustine and rituximab for
240 minutes.
Day 2, Cycle 3 –  Planned for 12/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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,Edward E [2435061]
10/9/2017 9:42:25 AM Page 14 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10 , Cycle 3 –  Planned for 12/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 15 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 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 –  1/1/2018 through 1/28/2018 (28 days), Planned
Day 1, Cycle 4 –  Planned for 1/1/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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+27 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+27 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+27 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 16 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

ALT/SGPT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and 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 Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion
complete. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension,
stop infusion and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during
which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 17 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT for bendamustine and rituximab for
240 minutes.
Day 2, Cycle 4 –  Planned for 1/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 18 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 19 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10 , Cycle 4 –  Planned for 1/10/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 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 –  1/29/2018 through 2/25/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 1/29/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 20 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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+27 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+27 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+27 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and 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 Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 21 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion
complete. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension,
stop infusion and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during
which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 22 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT for bendamustine and rituximab for
240 minutes.
Day 2, Cycle 5 –  Planned for 1/30/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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.
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 23 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10 , Cycle 5 –  Planned for 2/7/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 24 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 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 –  2/26/2018 through 3/25/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 2/26/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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+27 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+27 Approximate, Expires: S+365, Routine
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 25 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CREATININE
Expected: S+27 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and 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 Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion
complete. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension,
stop infusion and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during
which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 26 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT for bendamustine and rituximab for
240 minutes.
Day 2, Cycle 6 –  Planned for 2/27/2018
Treatment Plan Information
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 27 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 28 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10 , Cycle 6 –  Planned for 3/7/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 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 7 –  3/26/2018 through 4/22/2018 (28 days), Planned
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 29 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Day 1, Cycle 7 –  Planned for 3/26/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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+27 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+27 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+27 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and 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 Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 30 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion
complete. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension,
stop infusion and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during
which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 31 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT for bendamustine and rituximab for
240 minutes.
Day 2, Cycle 7 –  Planned for 3/27/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 32 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10 , Cycle 7 –  Planned for 4/4/2018
Treatment Plan Information
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 33 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 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 –  4/23/2018 through 5/20/2018 (28 days), Planned
Day 1, Cycle 8 –  Planned for 4/23/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 34 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+27 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+27 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+27 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+27 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT and 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 Creatinine Clearance less than or equal to 40 mL/min or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or
Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion
complete. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension,
stop infusion and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during
which the reaction occurred.
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.
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 35 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 36 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle):  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, AST, ALT and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT for bendamustine and rituximab for
240 minutes.
Day 2, Cycle 8 –  Planned for 4/24/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 37 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bendamustine (BENDEKA) 90 mg/m2 in sodium chloride 0.9 % 50 mL bag
90 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10 , Cycle 8 –  Planned for 5/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, bendamustine 90 mg/m2 IV Day 1 and 2;
CYCLE LENGTH: 28 days; COURSE: 6 to 8 cycles.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN),
some fatal, have been reported when bendamustine was administered concomitantly with allopurinol and other
medications known to cause these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor
lysis burden and risk for tumor lysis at initiation of treatment.
Note to All Staff (2)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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+8 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+8 Approximate, Expires: S+365, Routine
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 38 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Edward E [2435061]
10/9/2017 9:42:25 AM Page 39 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org