/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-96908-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(21D:1,4,8,11) Dexamethasone(21D:1,2,4,5,8,9,11,12) VER 10-3-16 (HL 1073)

CSC HEM Bortezomib(21D:1,4,8,11) Dexamethasone(21D:1,2,4,5,8,9,11,12) VER 10-3-16 (HL 1073) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM BORTEZOMIB(21D:1,4,8,11)/DEXAMETHASONE(21D:1,2,4,5,8,9,11,12) 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: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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, Normal, Routine
BUN
Expected-S Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 11/15/2016 through 12/5/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/15/2016
Treatment Plan Information
Reference Information (1)
MYELOMA: Jagannath S, et al. Br J Hematology 2005;29(6):776-83.
Reference Information (2)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 1 of 24
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.
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.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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): dexamethasone
Take Home Medications (delete all that do not apply)
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take on Day 1, 2, 4, 5, 8, 9, 11 and 12., 20 mg, Disp-40 tab, R-1, 1 X DAILY starting S, Local
Printer
Day 1, 4, 8, and 11 doses may be given in clinic.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take on Day 2, 5, 9, and 12., 20 mg, Disp-20 tab, R-1, 1 X DAILY starting S, Local Printer
Day 1, 4, 8, and 11 doses are given in clinic.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT:
bortezomib for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 2 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 4, Cycle 1 – Planned for 11/18/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Follow-Up
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: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 3 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Follow-Up
VERIFY APPOINTMENTS
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: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 4 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/6/2016 through 12/26/2016 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/6/2016
Treatment Plan Information
Reference Information (1)
MYELOMA: Jagannath S, et al. Br J Hematology 2005;29(6):776-83.
Reference Information (2)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 5 of 24
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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Take Home Medications (delete all that do not apply)
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take on Day 1, 2, 4, 5, 8, 9, 11 and 12., 20 mg, Disp-40 tab, R-1, 1 X DAILY starting S, Local
Printer
Day 1, 4, 8, and 11 doses may be given in clinic.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take on Day 2, 5, 9, and 12., 20 mg, Disp-20 tab, R-1, 1 X DAILY starting S, Local Printer
Day 1, 4, 8, and 11 doses are given in clinic.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT:
bortezomib for 30 minutes.
Day 4, Cycle 2 – Planned for 12/9/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 6 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
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 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 7 of 24
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.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
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 12/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Follow-Up
VERIFY APPOINTMENTS
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 8 of 24
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.
Cycle 3 – 12/27/2016 through 1/16/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 12/27/2016
Treatment Plan Information
Reference Information (1)
MYELOMA: Jagannath S, et al. Br J Hematology 2005;29(6):776-83.
Reference Information (2)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Normal, 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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 9 of 24
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.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Take Home Medications (delete all that do not apply)
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take on Day 1, 2, 4, 5, 8, 9, 11 and 12., 20 mg, Disp-40 tab, R-1, 1 X DAILY starting S, Local
Printer
Day 1, 4, 8, and 11 doses may be given in clinic.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take on Day 2, 5, 9, and 12., 20 mg, Disp-20 tab, R-1, 1 X DAILY starting S, Local Printer
Day 1, 4, 8, and 11 doses are given in clinic.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT:
bortezomib for 30 minutes.
Day 4, Cycle 3 – Planned for 12/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 10 of 24
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.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
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 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 11 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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 1/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 1/17/2017 through 2/6/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/17/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Jagannath S, et al. Br J Hematology 2005;29(6):776-83.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 12 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (2)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Normal, 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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 13 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Take Home Medications (delete all that do not apply)
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take on Day 1, 2, 4, 5, 8, 9, 11 and 12., 20 mg, Disp-40 tab, R-1, 1 X DAILY starting S, Local
Printer
Day 1, 4, 8, and 11 doses may be given in clinic.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take on Day 2, 5, 9, and 12., 20 mg, Disp-20 tab, R-1, 1 X DAILY starting S, Local Printer
Day 1, 4, 8, and 11 doses are given in clinic.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT:
bortezomib for 30 minutes.
Day 4, Cycle 4 – Planned for 1/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 14 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
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 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
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 1/27/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 15 of 24
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: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 2/7/2017 through 2/27/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 2/7/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Jagannath S, et al. Br J Hematology 2005;29(6):776-83.
Reference Information (2)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 16 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Normal, 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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Take Home Medications (delete all that do not apply)
dexamethasone (DECADRON) 4 MG tab
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 17 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take 5 tabs by mouth one time daily. Take on Day 1, 2, 4, 5, 8, 9, 11 and 12., 20 mg, Disp-40 tab, R-1, 1 X DAILY starting S, Local
Printer
Day 1, 4, 8, and 11 doses may be given in clinic.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take on Day 2, 5, 9, and 12., 20 mg, Disp-20 tab, R-1, 1 X DAILY starting S, Local Printer
Day 1, 4, 8, and 11 doses are given in clinic.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT:
bortezomib for 30 minutes.
Day 4, Cycle 5 – Planned for 2/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Follow-Up
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 18 of 24
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 5 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 5 – Planned for 2/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 19 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 2/28/2017 through 3/20/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 2/28/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Jagannath S, et al. Br J Hematology 2005;29(6):776-83.
Reference Information (2)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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+11 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 20 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Normal, 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.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Take Home Medications (delete all that do not apply)
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take on Day 1, 2, 4, 5, 8, 9, 11 and 12., 20 mg, Disp-40 tab, R-1, 1 X DAILY starting S, Local
Printer
Day 1, 4, 8, and 11 doses may be given in clinic.
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth one time daily. Take on Day 2, 5, 9, and 12., 20 mg, Disp-20 tab, R-1, 1 X DAILY starting S, Local Printer
Day 1, 4, 8, and 11 doses are given in clinic.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 21 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT:
bortezomib for 30 minutes.
Day 4, Cycle 6 – Planned for 3/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 6 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 cycles.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 22 of 24
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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 6 – Planned for 3/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 20 mg (fixed dose) by
mouth on Day 1, 2, 4, 5, 8, 9, 11 and 12; CYCLE LENGTH: 21 days; COURSE: 6 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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/15/2016 3:38:30 PM Page 23 of 24
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.
Treatment Medications
dexamethasone (DECADRON) tab 20 mg
20 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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
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 3:38:30 PM Page 24 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org