/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-96902-en.cckm

201605136

page

100

UWHC,UWMF,

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

CSC Hem Lenalidomide (28D9-28) Rituximab Ver 2-2-16 (HL 4793)

CSC Hem Lenalidomide (28D9-28) Rituximab Ver 2-2-16 (HL 4793) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM LENALIDOMIDE (28D:9-28)/RITUXIMAB VER: 2-2-16 – Properties
Cycle 1 – 2/4/2016 through 3/2/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 2/4/2016
Treatment Plan Information
Reference Information (1)
CHRONIC LYMPHOCYTIC LEUKEMIA: Badoux XC, et al. J Clin Onc. 2013;31:584-91.
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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 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
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 1 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

URIC ACID
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S Approximate, Expires-S+122, Routine
Pre-Labs
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
Expected-S Approximate, Expires-S+122, Routine
Pre-Labs (delete all that do not apply)
HEPATITIS B DNA, ULTRA QUANT, PCR
Approximate, Expires-S+122, Routine
Draw if Hepatitis B Core AB is positive.
HCG, QUALITATIVE, URINE
Expected-S Approximate, Expires-S+122, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8,
15, 22, 29 (Day 1 of next cycle)).
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 2 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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 10 UNIT/ML lock flush 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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 3 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth one time daily. Take on Days 1 through 7 during Cycle 1 only., 300 mg, Disp-7 tab,
R-0, 1 X DAILY starting S, Local Printer
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY 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
Take Home Medications (delete all that do not apply)
aspirin 325 MG EC tab
Take 1 tab by mouth one time daily., 325 mg, Disp-30 tab, R-11, 1 X DAILY starting S
enoxaparin (LOVENOX) 40 MG/0.4ML injection
Inject 40 mg under skin one time daily., 40 mg, Disp-30 Syringe, R-11, 1 X DAILY starting S
warfarin (COUMADIN) 5 MG tab
Take 1 tab by mouth one time daily at bedtime., 5 mg, Disp-30 tab, R-11, 1 X DAILY (HS) starting S
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth one time daily. Take during Induction Cycle only Days 1 through 14., 300 mg, Disp-
14 tab, R-0, 1 X DAILY starting S, Local Printer
For use in patients with moderate to severe risk of tumor lysis syndrome.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Urine Pregnancy test (for women of childbearing potential).
CHEMOTHERAPY ROOM APPOINTMENT: rituximab for 180 minutes.
DAY 9 FOLLOW-UP
LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, and Phosphate.
DAY 10 FOLLOW-UP
LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, and Phosphate.
DAY 11 FOLLOW-UP
LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, and Phosphate.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Urine Pregnancy test (for women of childbearing potential).
CHEMOTHERAPY ROOM APPOINTMENT: rituximab for 180 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Urine Pregnancy test (for women of childbearing potential).
CHEMOTHERAPY ROOM APPOINTMENT: rituximab for 180 minutes.
DAY 29 FOLLOW-UP
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 4 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin and
Urine Pregnancy test (for women of childbearing potential).
Day 8, Cycle 1 – Planned for 2/11/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+122, Routine
Treatment Conditions
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8,
15, 22, 29 (Day 1 of next cycle)).
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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 5 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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 10 UNIT/ML lock flush 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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 6 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 9, Cycle 1 – Planned for 2/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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
ELECTROLYTES
Expected-S+1 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+1 Approximate, Expires-S+365, Routine
BUN
Expected-S+1 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+1 Approximate, Expires-S+365, Routine
URIC ACID
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 7 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Expected-S+1 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
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 2/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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
ELECTROLYTES
Expected-S+2 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+2 Approximate, Expires-S+365, Routine
BUN
Expected-S+2 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+2 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+2 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 8 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

URIC ACID
Expected-S+2 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+2 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+2 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 11, Cycle 1 – Planned for 2/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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
ELECTROLYTES
Expected-S+3 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+3 Approximate, Expires-S+365, Routine
BUN
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+3 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 9 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

URIC ACID
Expected-S+3 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+3 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 2/18/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+122, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 10 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Conditions
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8,
15, 22, 29 (Day 1 of next cycle)).
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.
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 10 UNIT/ML lock flush 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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 11 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 – Planned for 2/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 12 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+122, Routine
Treatment Conditions
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8,
15, 22, 29 (Day 1 of next cycle)).
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.
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 10 UNIT/ML lock flush 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.
Emergency Medications
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 13 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 3/3/2016 through 3/30/2016 (28 days), Planned
Day 1, Cycle 2 – Planned for 3/3/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 14 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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 WITH DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 Approximate, Expires-S+122, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 15 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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 10 UNIT/ML lock flush 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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. CHEMOTHERAPY
ROOM APPOINTMENT: rituximab for 180 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Cycle 3 – 3/31/2016 through 4/27/2016 (28 days), Planned
Day 1, Cycle 3 – Planned for 3/31/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 16 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 17 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
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.
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 10 UNIT/ML lock flush 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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
Actions
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 18 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. CHEMOTHERAPY
ROOM APPOINTMENT: rituximab for 180 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Cycle 4 – 4/28/2016 through 5/25/2016 (28 days), Planned
Day 1, Cycle 4 – Planned for 4/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 19 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 20 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
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.
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 10 UNIT/ML lock flush 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,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 21 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. CHEMOTHERAPY
ROOM APPOINTMENT: rituximab for 180 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Cycle 5 – 5/26/2016 through 6/22/2016 (28 days), Planned
Day 1, Cycle 5 – Planned for 5/26/2016
Treatment Plan Information
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 22 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 23 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
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.
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 10 UNIT/ML lock flush 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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 24 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. CHEMOTHERAPY
ROOM APPOINTMENT: rituximab for 180 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 25 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Cycle 6 – 6/23/2016 through 7/20/2016 (28 days), Planned
Day 1, Cycle 6 – Planned for 6/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 26 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
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.
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 10 UNIT/ML lock flush 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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 27 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. CHEMOTHERAPY
ROOM APPOINTMENT: rituximab for 180 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 28 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Cycle 7 – 7/21/2016 through 8/17/2016 (28 days), Planned
Day 1, Cycle 7 – Planned for 7/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 29 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
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.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 30 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 31 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. CHEMOTHERAPY
ROOM APPOINTMENT: rituximab for 180 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Cycle 8 – 8/18/2016 through 9/14/2016 (28 days), Planned
Day 1, Cycle 8 – Planned for 8/18/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 32 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
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.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 33 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Actions
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 34 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. CHEMOTHERAPY
ROOM APPOINTMENT: rituximab for 180 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Cycle 9 – 9/15/2016 through 10/12/2016 (28 days), Planned
Day 1, Cycle 9 – Planned for 9/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 35 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Actions
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 36 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush 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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 37 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. CHEMOTHERAPY
ROOM APPOINTMENT: rituximab for 180 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Cycle 10 – 10/13/2016 through 11/9/2016 (28 days), Planned
Day 1, Cycle 10 – Planned for 10/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 38 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
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,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 39 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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 10 UNIT/ML lock flush 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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 40 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. CHEMOTHERAPY
ROOM APPOINTMENT: rituximab for 180 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Cycle 11 – 11/10/2016 through 12/7/2016 (28 days), Planned
Day 1, Cycle 11 – Planned for 11/10/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 41 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 42 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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 10 UNIT/ML lock flush 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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 43 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. CHEMOTHERAPY
ROOM APPOINTMENT: rituximab for 180 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Cycle 12 – 12/8/2016 through 1/4/2017 (28 days), Planned
Day 1, Cycle 12 – Planned for 12/8/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 44 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL or
Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
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
Actions
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 45 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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 10 UNIT/ML lock flush 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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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) 784 mg in sodium chloride 0.9 % 500 mL bag
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 46 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. NOTE: Urine
Pregnancy Test to be ordered by MD when required.
Cycle 13 – 1/5/2017 through 2/1/2017 (28 days), Planned
Day 1, Cycle 13 – Planned for 1/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 47 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL or
Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 48 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. NOTE: Urine
Pregnancy Test to be ordered by MD when required.
Cycle 14 – 2/2/2017 through 3/1/2017 (28 days), Planned
Day 1, Cycle 14 – Planned for 2/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 49 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 50 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. NOTE: Urine
Pregnancy Test to be ordered by MD when required.
Cycle 15 – 3/2/2017 through 3/29/2017 (28 days), Planned
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 51 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Day 1, Cycle 15 – Planned for 3/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 52 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 53 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. NOTE: Urine
Pregnancy Test to be ordered by MD when required.
Cycle 16 – 3/30/2017 through 4/26/2017 (28 days), Planned
Day 1, Cycle 16 – Planned for 3/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 54 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 55 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. NOTE: Urine
Pregnancy Test to be ordered by MD when required.
Cycle 17 – 4/27/2017 through 5/24/2017 (28 days), Planned
Day 1, Cycle 17 – Planned for 4/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 56 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:37:33 PM Page 57 of 60
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Uric Acid, Magnesium, Phosphate, Total Bilirubin. NOTE: Urine
Pregnancy Test to be ordered by MD when required.
Cycle 18 – 5/25/2017 through 6/21/2017 (28 days), Planned
Day 1, Cycle 18 – Planned for 5/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Chronic Lymphocytic Leukemia (Relapsed/Refractory); THERAPY: rituximab 375 mg/m2 IV
Days 1, 8, 15 and 22, lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 1
Cycle followed by THERAPY: lenalidomide 10 mg by mouth daily Days 9 through 28; CYCLE LENGTH: 28 days;
COURSE: 1 Cycle followed by THERAPY: rituximab 375 mg/m2 IV Day 1, lenalidomide 10 mg by mouth daily Days 9
through 28; CYCLE LENGTH: 28 days; COURSE: 10 Cycles followed by THERAPY: lenalidomide 10 mg by mouth once
daily Days 9 through 28; CYCLE LENGTH: 28 days; COURSE: 6 Cycles (maximum of 18 Cycles TOTAL).
Other
Note to All Staff (1)
Thrombosis prophylaxis recommended for all patients.
Treatment Plan Information
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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Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@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 WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 25K/µL
or Total Bilirubin greater than 2 mg/dL or Creatinine Clearance less than or equal to 30 mL/min.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for
females of childbearing potential with irregular periods on Day 15,and 29 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of
childbearing potential with regular periods on Day 29 (Day 1 of next cycle).
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Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lenalidomide
(dispensed Day 1 of each cycle).
Recommended Medication
Thrombosis Prophylaxis recommended for all patients. MD to select order.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 10 mg, Disp-21 cap, R-0, 1 X DAILY
starting S
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 9 through 28., 5 mg, Disp-21 cap, R-0, 1 X DAILY
starting S, Local Printer
Verify compliance with REVAssist Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider.
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Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org