/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-96888-en.cckm

201611327

page

100

UWHC,UWMF,

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

CSC HEM Rituximab With MINI-CHOP VER 10-3-16 (HL 4323)

CSC HEM Rituximab With MINI-CHOP VER 10-3-16 (HL 4323) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM RITUXIMAB WITH MINI-CHOP VER: 10-3-16 – Properties
Pre-Cycle – 11/15/2016 through 11/21/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1, vinCRIStine 1 mg
IV Day 1, cyclophosphamide 400 mg/m2 IV Day 1, prednisone 100 mg by mouth Day 1,2,3,4,and 5; CYCLE LENGTH: 21 days;
COURSE: Maximum 6 to 8 cycles
Note to All Staff (1)
Use caution with this regimen in patients greater than or equal to 80 years of age.
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 WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
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
HEPATITIS B CORE AB, TOTAL
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AG
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AB
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 1 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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-11, 2 X DAILY starting S, Local Printer
Cycle 1 – 11/22/2016 through 12/12/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Reference Information (1)
LYMPHOMA: Peyrade F, et al. Lancet Oncol 2011;12: 460-68
Reference Information (2)
LYMPHOMA: Plosker GL, et al. Drugs 2003;63(8):803-43
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1, vinCRIStine 1 mg
IV Day 1, cyclophosphamide 400 mg/m2 IV Day 1, prednisone 100 mg by mouth Day 1,2,3,4,and 5; CYCLE LENGTH: 21 days;
COURSE: Maximum 6 to 8 cycles
Note to All Staff (1)
Use caution with this regimen in patients greater than or equal to 80 years of age.
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
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.
Pre-Labs
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, Calcium, Uric Acid, LDH
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 2 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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.
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.
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 3 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk. See Emergency Medications. 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.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 1 mg in sodium chloride 0.9 % 25 mL bag
1 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 716 mg in sodium chloride 0.9 % 250 mL bag
716 mg (400 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
Refer to the Cycle 1 Day 1 take home medications section for the following treatment medication(s): predniSONE
Take Home Medications
prednisone (DELTASONE) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Day 1 through 5., 100 mg, Disp-10 tab, R-8, 1 X DAILY starting S, Local Printer
Day 1 dose given as premedication in clinic
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: rituximab, cyclophosphamide, doxorubicin CONVENTIONAL, vinCRIStine,
prednisone for 210 minutes.
Cycle 2 – 12/13/2016 through 1/2/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1, vinCRIStine 1 mg
IV Day 1, cyclophosphamide 400 mg/m2 IV Day 1, prednisone 100 mg by mouth Day 1,2,3,4,and 5; CYCLE LENGTH: 21 days;
COURSE: Maximum 6 to 8 cycles
Note to All Staff (1)
Use caution with this regimen in patients greater than or equal to 80 years of age.
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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 4 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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.
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.
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 5 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk. See Emergency Medications. 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.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 1 mg in sodium chloride 0.9 % 25 mL bag
1 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 716 mg in sodium chloride 0.9 % 250 mL bag
716 mg (400 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: rituximab, cyclophosphamide, doxorubicin CONVENTIONAL, vinCRIStine,
prednisone for 210 minutes.
Cycle 3 – 1/3/2017 through 1/23/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1, vinCRIStine 1 mg
IV Day 1, cyclophosphamide 400 mg/m2 IV Day 1, prednisone 100 mg by mouth Day 1,2,3,4,and 5; CYCLE LENGTH: 21 days;
COURSE: Maximum 6 to 8 cycles
Note to All Staff (1)
Use caution with this regimen in patients greater than or equal to 80 years of age.
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,Andrew [2428787]
11/22/2016 12:37:33 PM Page 6 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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.
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.
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 7 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk. See Emergency Medications. 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.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 1 mg in sodium chloride 0.9 % 25 mL bag
1 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 716 mg in sodium chloride 0.9 % 250 mL bag
716 mg (400 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: rituximab, cyclophosphamide, doxorubicin CONVENTIONAL, vinCRIStine,
prednisone for 210 minutes.
Cycle 4 – 1/24/2017 through 2/13/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1, vinCRIStine 1 mg
IV Day 1, cyclophosphamide 400 mg/m2 IV Day 1, prednisone 100 mg by mouth Day 1,2,3,4,and 5; CYCLE LENGTH: 21 days;
COURSE: Maximum 6 to 8 cycles
Note to All Staff (1)
Use caution with this regimen in patients greater than or equal to 80 years of age.
Note to All Staff (2)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 8 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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.
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.
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 9 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk. See Emergency Medications. 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.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 1 mg in sodium chloride 0.9 % 25 mL bag
1 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 716 mg in sodium chloride 0.9 % 250 mL bag
716 mg (400 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: rituximab, cyclophosphamide, doxorubicin CONVENTIONAL, vinCRIStine,
prednisone for 210 minutes.
Cycle 5 – 2/14/2017 through 3/6/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 2/14/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 10 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1, vinCRIStine 1 mg
IV Day 1, cyclophosphamide 400 mg/m2 IV Day 1, prednisone 100 mg by mouth Day 1,2,3,4,and 5; CYCLE LENGTH: 21 days;
COURSE: Maximum 6 to 8 cycles
Note to All Staff (1)
Use caution with this regimen in patients greater than or equal to 80 years of age.
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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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.
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.
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 11 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk. See Emergency Medications. 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.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 1 mg in sodium chloride 0.9 % 25 mL bag
1 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 716 mg in sodium chloride 0.9 % 250 mL bag
716 mg (400 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 12 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally),
Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: rituximab, cyclophosphamide, doxorubicin
CONVENTIONAL, vinCRIStine, prednisone for 210 minutes.
Cycle 6 – 3/7/2017 through 3/27/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1, vinCRIStine 1 mg
IV Day 1, cyclophosphamide 400 mg/m2 IV Day 1, prednisone 100 mg by mouth Day 1,2,3,4,and 5; CYCLE LENGTH: 21 days;
COURSE: Maximum 6 to 8 cycles
Note to All Staff (1)
Use caution with this regimen in patients greater than or equal to 80 years of age.
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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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.
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.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 13 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk. See Emergency Medications. 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.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 1 mg in sodium chloride 0.9 % 25 mL bag
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 14 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 716 mg in sodium chloride 0.9 % 250 mL bag
716 mg (400 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: rituximab, cyclophosphamide, doxorubicin CONVENTIONAL, vinCRIStine,
prednisone for 210 minutes.
Cycle 7 – 3/28/2017 through 4/17/2017 (21 days), Planned
Day 1, Cycle 7 – Planned for 3/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1, vinCRIStine 1 mg
IV Day 1, cyclophosphamide 400 mg/m2 IV Day 1, prednisone 100 mg by mouth Day 1,2,3,4,and 5; CYCLE LENGTH: 21 days;
COURSE: Maximum 6 to 8 cycles
Note to All Staff (1)
Use caution with this regimen in patients greater than or equal to 80 years of age.
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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 15 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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.
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.
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 16 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk. See Emergency Medications. 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.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 1 mg in sodium chloride 0.9 % 25 mL bag
1 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 716 mg in sodium chloride 0.9 % 250 mL bag
716 mg (400 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: rituximab, cyclophosphamide, doxorubicin CONVENTIONAL, vinCRIStine,
prednisone for 210 minutes.
Cycle 8 – 4/18/2017 through 5/8/2017 (21 days), Planned
Day 1, Cycle 8 – Planned for 4/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1, vinCRIStine 1 mg
IV Day 1, cyclophosphamide 400 mg/m2 IV Day 1, prednisone 100 mg by mouth Day 1,2,3,4,and 5; CYCLE LENGTH: 21 days;
COURSE: Maximum 6 to 8 cycles
Note to All Staff (1)
Use caution with this regimen in patients greater than or equal to 80 years of age.
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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 17 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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.
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.
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 18 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk. See Emergency Medications. 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.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 1 mg in sodium chloride 0.9 % 25 mL bag
1 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 716 mg in sodium chloride 0.9 % 250 mL bag
716 mg (400 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: rituximab, cyclophosphamide, doxorubicin CONVENTIONAL, vinCRIStine,
prednisone for 210 minutes.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:37:33 PM Page 19 of 19
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org