/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---myeloma/,

/clinical/cckm-tools/content/beacon-protocols/hem---myeloma/name-111807-en.cckm

20170120

page

100

UWHC,UWMF,

Tools,

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

CSC HEM Lenalidomide(28D:1-21) Myeloma VER 1-17-17 (HL 6264)

CSC HEM Lenalidomide(28D:1-21) Myeloma VER 1-17-17 (HL 6264) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM LENALIDOMIDE (28D:1-21) (MYELOMA) VER: 1-17-17 – Properties
Pre-Cycle – 1/10/2017 through 1/16/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 1/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
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
ALBUMIN
Expected-S Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S Approximate, Expires-S+365, Routine
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 1 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

Take Home Medications
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
Take Home Medications (delete all that do not apply)
Recommended Medication
Thrombosis Prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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
Cycle 1 – 1/17/2017 through 2/13/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 1/17/2017
Treatment Plan Information
Reference Information (1)
MULTIPLE MYELOMA: McCarthy PL, et al. N Engl J Med 2012;366(10):1770-81.
Reference Information (2)
MULTIPLE MYELOMA: Palumbo A, et al. N Engl J Med 2012;366(19):1759-69.
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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 (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 2 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 75K/µL or Creatinine
Clearance less than 60 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
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.
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).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Days 1 through 21 of Cycle., 10 mg, Disp-21 cap, R-0, 1 X DAILY starting S
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist with coordinate drug ordering.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential).
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential).
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, Total LD, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase and Urine Pregnancy Test (for
women of child-bearing potential).
Lab Only - Day 8, Cycle 1 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 3 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@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+7 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+7 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 15, Cycle 1 – Planned for 1/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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+14 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 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 22, Cycle 1 – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 4 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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+21 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 2/14/2017 through 3/13/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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
LD, TOTAL
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
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 5 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 75K/µL or Creatinine Clearance less than 60
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 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.
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).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 6 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@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 1 through 21., 10 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS 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 1 through 21., 5 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 2.5 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 2.5 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential).
DAY 22 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, Total LD, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase and Urine Pregnancy Test (for
women of child-bearing potential).
Lab Only - Day 8, Cycle 2 – Planned for 2/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 2 – Planned for 2/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 7 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+14 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 22, Cycle 2 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 3/14/2017 through 4/10/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 3/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
Consent
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 8 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
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
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 75K/µL or Creatinine Clearance less than 60
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,Edward E [2435061]
1/17/2017 8:52:35 AM Page 9 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@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 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.
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).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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 1 through 21., 10 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS 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 1 through 21., 5 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 2.5 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 2.5 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential).
DAY 22 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, Total LD, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase and Urine Pregnancy Test (for
women of child-bearing potential).
Lab Only - Day 8, Cycle 3 – Planned for 3/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 10 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 – Planned for 3/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+14 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 22, Cycle 3 – Planned for 4/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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,Edward E [2435061]
1/17/2017 8:52:35 AM Page 11 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 4/11/2017 through 5/8/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 4/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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
LD, TOTAL
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
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 12 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 75K/µL or Creatinine Clearance less than 60
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 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.
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).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 15 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 15 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 10 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS 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 1 through 21., 5 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 13 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

lenalidomide (REVLIMID) 2.5 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 2.5 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential).
DAY 22 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, Total LD, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase and Urine Pregnancy Test (for
women of child-bearing potential).
Lab Only - Day 8, Cycle 4 – Planned for 4/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 4 – Planned for 4/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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,Edward E [2435061]
1/17/2017 8:52:35 AM Page 14 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 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 22, Cycle 4 – Planned for 5/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 5/9/2017 through 6/5/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 5/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 15 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@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
LD, TOTAL
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
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 75K/µL or Creatinine Clearance less than 60
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
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 16 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 15 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 15 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 10 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS 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 1 through 21., 5 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 2.5 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 2.5 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential).
DAY 22 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, Total LD, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase and Urine Pregnancy Test (for
women of child-bearing potential).
Lab Only - Day 8, Cycle 5 – Planned for 5/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 17 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 5 – Planned for 5/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
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+14 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 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 22, Cycle 5 – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 18 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 6/6/2017 through 7/3/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 6/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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
LD, TOTAL
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
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 19 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 750/µL or Platelets less than 75K/µL or Creatinine Clearance less than 60
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 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.
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).
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 15 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 15 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 10 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 20 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

lenalidomide (REVLIMID) 5 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 5 mg, Disp-21 cap, R-0, 1 X DAILY starting S,
Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug
ordering.
lenalidomide (REVLIMID) 2.5 MG cap
Take 1 cap by mouth one time daily. Take on Day 1 through 21., 2.5 mg, Disp-21 cap, R-0, 1 X DAILY starting S, Local Printer
Verify compliance with REVLIMID REMS Program. Indication is Cancer Treatment. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Urine Pregnancy Test (women of childbearing potential).
DAY 22 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider. LABS: CBC with DIFF, Total LD, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase and Urine Pregnancy Test (for
women of child-bearing potential).
Lab Only - Day 8, Cycle 6 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 6 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome; THERAPY: lenalidomide 10 mg by mouth once daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression
Note to All Staff (1)
Thrombosis prophylaxis can be considered but is not required for MDS patients receiving lenalidomide.
IV Access
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 21 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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+14 Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S+14 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 22, Cycle 6 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Maintenance); THERAPY: lenalidomide 10 mg by mouth once daily Day 1 through 21; CYCLE
LENGTH: 28 days; COURSE: until disease progression
Note: For patients who are POST-TRANSPLANT, the dose may be increased to 15 mg after three cycles of therapy if patient is
tolerating therapy and has a stable ANC and platelet count.
Note to All Staff (1)
Thrombosis prophylaxis should be considered for high-risk patients (history of DVT/PE, significant family history, performance status
greater than or equal to 2, smoking history, use of oral contraceptives, concurrent use of epoetin, diabetes mellitus, or coronary
artery disease).
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+21 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Edward E [2435061]
1/17/2017 8:52:35 AM Page 22 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org