/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-96907-en.cckm

201611320

page

100

UWHC,UWMF,

Tools,

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

CSC HEM Bortezomib Melphalan Prednisone VER 10-3-16 (HL 4695)

CSC HEM Bortezomib Melphalan Prednisone VER 10-3-16 (HL 4695) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM BORTEZOMIB/MELPHALAN/PREDNISONE VER:10-3-16 – Properties
Pre-Cycle – 11/8/2016 through 11/14/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/8/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily. Take continuously., 400 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S, Local Printer
Cycle 1 – 11/15/2016 through 12/26/2016 (42 days), Planned
Day 1, Cycle 1 – Planned for 11/15/2016
Treatment Plan Information
Reference Information (1)
MULTIPLE MYELOMA: San Miguel J, et al. N Engl J Med 2008;(359(9):906-17.
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
Consent
Verify Consent
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 1 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 110 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
prednisone (DELTASONE) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 100 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 2 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 25 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 32 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
Day 4, Cycle 1 – Planned for 11/18/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 3 of 56
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 8, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+4 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+4 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 4 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 1 – Planned for 11/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 5 of 56
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+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 25, Cycle 1 – Planned for 12/9/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 6 of 56
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 1 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+4 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+4 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 7 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to
75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 32, Cycle 1 – Planned for 12/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 8 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/27/2016 through 2/6/2017 (42 days), Planned
Day 1, Cycle 2 – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
BUN
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
AST/SGOT
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 9 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 110 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
prednisone (DELTASONE) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 100 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 10 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 25 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 32 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
Day 4, Cycle 2 – Planned for 12/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 2 – Planned for 1/3/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 11 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+4 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+4 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 2 – Planned for 1/6/2017
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 12 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 2 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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,Andrew [2428787]
11/15/2016 3:49:44 PM Page 13 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 25, Cycle 2 – Planned for 1/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 14 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 2 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+4 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+4 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 15 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 32, Cycle 2 – Planned for 1/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 16 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 2/7/2017 through 3/20/2017 (42 days), Planned
Day 1, Cycle 3 – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
BUN
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 17 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to
75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 110 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
prednisone (DELTASONE) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 100 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 25 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 32 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 18 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
Day 4, Cycle 3 – Planned for 2/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 3 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 19 of 56
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+4 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+4 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 3 – Planned for 2/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 20 of 56
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 3 – Planned for 2/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 21 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 25, Cycle 3 – Planned for 3/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 22 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 3 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+4 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+4 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 23 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 32, Cycle 3 – Planned for 3/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 24 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 3/21/2017 through 5/1/2017 (42 days), Planned
Day 1, Cycle 4 – Planned for 3/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
BUN
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 25 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 110 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
prednisone (DELTASONE) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 100 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 25 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 32 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 26 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 4, Cycle 4 – Planned for 3/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 4 – Planned for 3/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 27 of 56
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+4 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+4 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 4 – Planned for 3/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 28 of 56
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 4 – Planned for 4/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 29 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to
75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 25, Cycle 4 – Planned for 4/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 30 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 4 – Planned for 4/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+4 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+4 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 31 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 32, Cycle 4 – Planned for 4/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 32 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 5/2/2017 through 6/12/2017 (42 days), Planned
Day 1, Cycle 5 – Planned for 5/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
BUN
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 33 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 110 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
prednisone (DELTASONE) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 100 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
Day 8, Cycle 5 – Planned for 5/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 34 of 56
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 Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 5 – Planned for 5/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 35 of 56
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 5 – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 36 of 56
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 Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 6/13/2017 through 7/24/2017 (42 days), Planned
Day 1, Cycle 6 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
Consent
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 37 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+13 Approximate, Expires-S+365, Routine
BUN
Expected-S+13 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+13 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+13 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+13 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 38 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 110 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
prednisone (DELTASONE) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 100 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
Day 8, Cycle 6 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 39 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 6 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 40 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 6 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 41 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 7/25/2017 through 9/4/2017 (42 days), Planned
Day 1, Cycle 7 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+13 Approximate, Expires-S+365, Routine
BUN
Expected-S+13 Approximate, Expires-S+365, Routine
CREATININE
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 42 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+13 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+13 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+13 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 110 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
prednisone (DELTASONE) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 100 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 43 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30
minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
Day 8, Cycle 7 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 44 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 7 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 45 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 7 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 46 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 9/5/2017 through 10/16/2017 (42 days), Planned
Day 1, Cycle 8 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+13 Approximate, Expires-S+365, Routine
BUN
Expected-S+13 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+13 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+13 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+13 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 47 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 110 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
prednisone (DELTASONE) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 100 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
Day 8, Cycle 8 – Planned for 9/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 48 of 56
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 Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 8 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 49 of 56
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 8 – Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 50 of 56
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 Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 9 – 10/17/2017 through 11/27/2017 (42 days), Planned
Day 1, Cycle 9 – Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
Consent
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 51 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+13 Approximate, Expires-S+365, Routine
BUN
Expected-S+13 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+13 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+13 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+13 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 52 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 110 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
prednisone (DELTASONE) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Days 1 through 4 of Cycle., 100 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79
m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
Day 8, Cycle 9 – Planned for 10/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 53 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 9 – Planned for 11/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 54 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 9 – Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (non-transplant candidate); THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone
60 mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 4, 8, 11, 22, 25, 29, and 32; CYCLE
LENGTH: 42 days; COURSE: 4 cycles followed by THERAPY: melphalan 9 mg/m2 by mouth Days 1, 2, 3, and 4, prednisone 60
mg/m2 by mouth Days 1, 2, 3, and 4, bortezomib 1.3 mg/m2 subcutaneous Days 1, 8, 22, and 29; CYCLE LENGTH: 42 days;
COURSE: 5 cycles.
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, 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 55 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:49:44 PM Page 56 of 56
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org