/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-96906-en.cckm

201611327

page

100

UWHC,UWMF,

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

CSC HEM Stanford V VER 10-3-16 (HL 1061)

CSC HEM Stanford V VER 10-3-16 (HL 1061) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM STANFORD V VER: 10-3-16 – Properties
Pre-Cycle – 11/15/2016 through 11/21/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Normal, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following mechlorethamine., 80 mg, Disp-2 cap, R-2, 1 X DAILY starting S
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
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tablet by mouth twice daily on Saturday and Sunday., Disp-16 tab, R-5, starting S
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 1 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take Home Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth one time daily. Take during Cycle 1 only., 300 mg, Disp-10 tab, R-0, 1 X DAILY starting S, Local Printer
Cycle 1 – 11/22/2016 through 12/19/2016 (28 days), Planned
Day 1 (Week 1), Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Reference Information (1)
HODGKIN LYMPHOMA: Bartlett NL, et al. J Clin Oncol 1995;13:1080-8.
Reference Information (2)
HODGKIN LYMPHOMA: Horning SJ, et al. J Clin Oncol 2002;20(3):630-7.
Reference Information (3)
HODGKIN LYMPHOMA: Hoskin PJ, et al. J Clin Oncol 2009;27(32):5390-96.
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Total
Bilirubin greater than upper limits of normal.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 2 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
mechlorethamine (MUSTARGEN) injection 10.7 mg
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
Into running IV line, use immediately. Hypersensitivity risk. See Emergency Medications.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
NOTE: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks 9 and 11.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Take Home Medications
prednisone (DELTASONE) 10 MG tab
Take 4 tabs by mouth every other day. Take for 9 weeks., 40 mg, EVERY OTHER DAY starting S
Dose of prednisone tapered by 10 mg every other day starting on week 10 (see new RX on week 10). If taper has begin prior to
week 10, modify as appropriate.
Follow-Up (delete all that do not apply)
DAY 3 FOLLOW-UP
LABS: Potasium, Uric Acid, LDH, Creatinine.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potasium (delete if not needed), Creatinine (delete if not needed), Uric Acid (delete if
not needed), LDH (delete if not needed); CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine and bleomycin for 45 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, vinBLAStine and etoposide for 90 minutes.
DAY 16 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide for 60 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, and bleomycin for 45 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: mechlorethamine, doxorubicin, vinBLAStine for 60 minutes.
Lab Only - Day 3 (Delete if not needed), Cycle 1 – Planned for 11/24/2016
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 3 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
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
CREATININE
Expected-S+2 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+2 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+2 Approximate, Expires-S+365, Routine
LD, TOTAL
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.
Day 8 (Week 2), Cycle 1 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
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)
CREATININE
Expected-S+7 Approximate, Expires-S+397, Normal, Routine
POTASSIUM
Expected-S+7 Approximate, Expires-S+397, Normal, Routine
URIC ACID
Expected-S+7 Approximate, Expires-S+122, Normal, Routine
LD, TOTAL
Expected-S+7 Approximate, Expires-S+122, Normal, Routine
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 4 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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 30 minutes prior to bleomycin. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for
peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to bleomycin.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
vinCRIStine (ONCOVIN) 2.5 mg in sodium chloride 0.9 % 25 mL bag
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg. NOTE: Patients
greater than 50 years of age, dose reduced to 1 mg/m2 on weeks 10 and 12.
bleomycin (BLENOXANE) 9 units in sodium chloride 0.9 % 100 mL bag
9 units (rounded from 8.95 units = 5 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Follow-Up
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 5 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 (Week 3), Cycle 1 – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
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
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
NOTE: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks 9 and 11.
etoposide (VEPESID) 107 mg in sodium chloride 0.9 % 500 mL NSS bag
107 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 6 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 16, Cycle 1 – Planned for 12/7/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
etoposide (VEPESID) 107 mg in sodium chloride 0.9 % 500 mL NSS bag
107 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22 (Week 4), Cycle 1 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 7 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC and ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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 30 minutes prior to bleomycin. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for
peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to bleomycin.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 8 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
vinCRIStine (ONCOVIN) 2.5 mg in sodium chloride 0.9 % 25 mL bag
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg. NOTE: Patients
greater than 50 years of age, dose reduced to 1 mg/m2 on weeks 10 and 12.
bleomycin (BLENOXANE) 9 units in sodium chloride 0.9 % 100 mL bag
9 units (rounded from 8.95 units = 5 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/20/2016 through 1/16/2017 (28 days), Planned
Day 1 (Week 5), Cycle 2 – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 9 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC and ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
mechlorethamine (MUSTARGEN) injection 10.7 mg
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
Into running IV line, use immediately. Hypersensitivity risk. See Emergency Medications.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 10 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
NOTE: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks 9 and 11.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine and bleomycin for 45
minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, vinBLAStine and etoposide
for 90 minutes.
DAY 16 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide for 60 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, and bleomycin for 45
minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: mechlorethamine, doxorubicin, vinBLAStine for 60 minutes.
Day 8 (Week 6), Cycle 2 – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
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
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
Hydration
sodium chloride 0.9 % infusion
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 11 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 30 minutes prior to bleomycin. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for
peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to bleomycin.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
vinCRIStine (ONCOVIN) 2.5 mg in sodium chloride 0.9 % 25 mL bag
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg. NOTE: Patients
greater than 50 years of age, dose reduced to 1 mg/m2 on weeks 10 and 12.
bleomycin (BLENOXANE) 9 units in sodium chloride 0.9 % 100 mL bag
9 units (rounded from 8.95 units = 5 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 (Week 7), Cycle 2 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 12 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
NOTE: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks 9 and 11.
etoposide (VEPESID) 107 mg in sodium chloride 0.9 % 500 mL NSS bag
107 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 16, Cycle 2 – Planned for 1/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 13 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
etoposide (VEPESID) 107 mg in sodium chloride 0.9 % 500 mL NSS bag
107 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22 (Week 8), Cycle 2 – Planned for 1/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
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+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 14 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC and ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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 30 minutes prior to bleomycin. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for
peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to bleomycin.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
vinCRIStine (ONCOVIN) 2.5 mg in sodium chloride 0.9 % 25 mL bag
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg. NOTE: Patients
greater than 50 years of age, dose reduced to 1 mg/m2 on weeks 10 and 12.
bleomycin (BLENOXANE) 9 units in sodium chloride 0.9 % 100 mL bag
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 15 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

9 units (rounded from 8.95 units = 5 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/17/2017 through 2/13/2017 (28 days), Planned
Day 1 (Week 9), Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 16 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC and ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
mechlorethamine (MUSTARGEN) injection 10.7 mg
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
Into running IV line, use immediately. Hypersensitivity risk. See Emergency Medications.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
NOTE: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks 9 and 11.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine and bleomycin for 45
minutes.
DAY 15 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 17 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin,
vinBLAStine and etoposide for 90 minutes.
DAY 16 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide for 60 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, and bleomycin for 45
minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: mechlorethamine, doxorubicin, vinBLAStine for 60 minutes.
Day 8 (Week 10), Cycle 3 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC and ANC.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
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 30 minutes prior to bleomycin. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for
peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 18 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to bleomycin.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
vinCRIStine (ONCOVIN) 2.5 mg in sodium chloride 0.9 % 25 mL bag
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg. NOTE: Patients
greater than 50 years of age, dose reduced to 1 mg/m2 on weeks 10 and 12.
bleomycin (BLENOXANE) 9 units in sodium chloride 0.9 % 100 mL bag
9 units (rounded from 8.95 units = 5 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Take Home Medications
prednisone (DELTASONE) 10 MG tab
Take 3 tab orally every other day x1 wk then 2 tab every other day x1 wk, 1 tab every other day x1 wk, R-0, starting S
Start on week 10. If taper has begun prior to Week 10, modify directions as appropriate.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 (Week 11), Cycle 3 – Planned for 1/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
IV Access
Insert and Maintain Peripheral IV
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 19 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 45 mg
45 mg (rounded from 44.75 mg = 25 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinBLAStine (VELBAN) 10.7 mg in sodium chloride 0.9 % 25 mL bag
10.7 mg (rounded from 10.74 mg = 6 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
NOTE: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks 9 and 11.
etoposide (VEPESID) 107 mg in sodium chloride 0.9 % 500 mL NSS bag
107 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 16, Cycle 3 – Planned for 2/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 20 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
etoposide (VEPESID) 107 mg in sodium chloride 0.9 % 500 mL NSS bag
107 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22 (Week 12), Cycle 3 – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Hodgkin Lymphoma; THERAPY: mechlorethamine 6 mg/m2 IV Day 1, doxorubicin 25 mg/m2 IV Day 1 and 15,
vinBLAStine 6 mg/m2 IV Day 1 and 15, vinCRIStine 1.4 mg/m2 IV (maximum 2 mg) Day 8 and 22, bleomycin 5 units/m2 IV Day 8
and 22, etoposide 60 mg/m2 IV Day 15 and 16, prednisone 40 mg PO every other day Day 1 through 28; CYCLE LENGTH: 28 days;
COURSE: 3 cycles (12 weeks); NOTE 1: Patients greater than 50 years of age, vinBLAStine dose reduced to 4 mg/m2 IV on weeks
9 and 11 and vinCRIStine dose reduced to 1 mg/m2 on weeks 10 and 12. NOTE 2: Dose of prednisone tapered by 10 mg every
other day, starting on week 10.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 21 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC and ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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 30 minutes prior to bleomycin. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for
peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to bleomycin.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 22 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

vinCRIStine (ONCOVIN) 2.5 mg in sodium chloride 0.9 % 25 mL bag
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
NOTE: Patients greater than 50 years of age, dose reduced to 1 mg/m2 on weeks 10 and 12.
bleomycin (BLENOXANE) 9 units in sodium chloride 0.9 % 100 mL bag
9 units (rounded from 8.95 units = 5 Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Patient should be monitored for 30 minutes after first dose of bleomycin. Hypersensitivity risk. See emergency medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed on Week 1 and Week
10).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:42:07 PM Page 23 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org