/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-96909-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:1,8,15) Lenalidomide(21D:1-14) VER 10-3-16 (HL 3535)

CSC HEM Bortezomib(21D:1,4,8,11) Dexamethasone(21D:1,8,15) Lenalidomide(21D:1-14) VER 10-3-16 (HL 3535) - 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:1,8,15)/LENALIDOMIDE(21D:1-14) 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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
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
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
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
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-7, 2 X DAILY starting S, Local Printer
Take Home Medications (delete all that do not apply)
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
aspirin 325 MG EC tab
Take 1 tab by mouth one time daily., 325 mg, Disp-30 tab, R-11, 1 X DAILY starting S
enoxaparin (LOVENOX) 40 MG/0.4ML injection
Inject 40 mg under skin one time daily., 40 mg, Disp-30 Syringe, R-11, 1 X DAILY starting S
warfarin (COUMADIN) 5 MG tab
Take 1 tab by mouth one time daily at bedtime., 5 mg, Disp-30 tab, R-11, 1 X DAILY (HS) starting S
Cycle 1 – 11/15/2016 through 12/5/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/15/2016
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 1 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (1)
MYELOMA: Richardson P et al. Blood. 2008; 112: Abstract 92.
Reference Information (2)
MYELOMA: Richardson P et al. Blood. 2008; 112: Abstract 1742.
Reference Information (3)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Myeloma: THERAPY: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 70K/µL, Creatinine Clearance less
than 60 mL/min, Total Bilirubin greater than or equal to 1.5 X ULN or AST greater than or equal to 2.5 X ULN.
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8, 15, 22 (Day 1 of next cycle)).
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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 3:41:01 PM Page 2 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): lenalidomide and
dexamethasone
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth once weekly. Take on Day 1, 8 and 15., 40 mg, Disp-30 tab, R-7, EVERY 7 DAYS starting S, Local Printer
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 5 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes; NOTE: Urine pregnancy test to be ordered by MD when
required.
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 with DIFF, Creatinine, Total Bilirubin, AST,
NOTE: Urine pregnancy test to be ordered by MD when required; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30
minutes
Day 4, Cycle 1 – Planned for 11/18/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma: THERAPY: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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 3:41:01 PM Page 3 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide
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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
Treatment Conditions
Treatment Condition A
CYCLE 1 ONLY: Order Urine Pregnancy Test WEEKLY for females of childbearing potential (Day 1, 8, 15, 22 (Day 1 of next cycle)).
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide and dexamethasone
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 4 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma: THERAPY: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide
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
Treatment Plan Summary
DISEASE: Myeloma: THERAPY: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 5 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 with DIFF, Creatinine, Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 70K/µL, Creatinine Clearance less
than 60 mL/min, Total Bilirubin greater than or equal to 1.5 X ULN or AST greater than or equal to 2.5 X ULN.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15,and 22 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 22 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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): lenalidomide; Refer to the Cycle 1 Day 1 take
home medications section for the following treatment medication(s): dexamethasone
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 5 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 15 MG cap
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 6 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes; NOTE: Urine pregnancy test to be ordered by MD when
required.
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 with DIFF, Creatinine, Total Bilirubin, AST,
NOTE: Urine pregnancy test to be ordered by MD when required; 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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 7 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma: THERAPY: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide; Refer to the Cycle 1 Day 1
take home medications section for the following treatment medication(s): dexamethasone
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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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 3:41:01 PM Page 8 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 Day 1 take home medications section for the following treatment medication(s): lenalidomide
Follow-Up
VERIFY APPOINTMENTS
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
Treatment Plan Summary
DISEASE: Myeloma: THERAPY: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+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 with DIFF, Creatinine, Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 70K/µL, Creatinine Clearance less
than 60 mL/min, Total Bilirubin greater than or equal to 1.5 X ULN or AST greater than or equal to 2.5 X ULN.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15,and 22 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 22 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 9 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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): lenalidomide; Refer to the Cycle 1 Day 1 take
home medications section for the following treatment medication(s): dexamethasone
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 5 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes; NOTE: Urine pregnancy test to be ordered by MD when
required.
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 with DIFF, Creatinine, Total Bilirubin, AST,
NOTE: Urine pregnancy test to be ordered by MD when required; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30
minutes
Day 4, Cycle 3 – Planned for 12/30/2016
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 10 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Myeloma: THERAPY: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide
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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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 3:41:01 PM Page 11 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 Day 1 take home medications section for the following treatment medication(s): lenalidomide; Refer to the Cycle 1 Day 1
take home medications section for the following treatment medication(s): dexamethasone
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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide
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
Treatment Plan Summary
DISEASE: Myeloma: THERAPY: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 12 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification
note and delete Day 4 and 11 from treatment plan.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+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 with DIFF, Creatinine, Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 70K/µL, Creatinine Clearance less
than 60 mL/min, Total Bilirubin greater than or equal to 1.5 X ULN or AST greater than or equal to 2.5 X ULN.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15,and 22 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 22 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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): lenalidomide; Refer to the Cycle 1 Day 1 take
home medications section for the following treatment medication(s): dexamethasone
Take Home Medications
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 13 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 5 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes; NOTE: Urine pregnancy test to be ordered by MD when
required.
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 with DIFF, Creatinine, Total Bilirubin, AST,
NOTE: Urine pregnancy test to be ordered by MD when required; 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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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 3:41:01 PM Page 14 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment 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 Day 1 take home medications section for the following treatment medication(s): lenalidomide
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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide; Refer to the Cycle 1 Day 1
take home medications section for the following treatment medication(s): dexamethasone
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
Treatment Plan Summary
DISEASE: Myeloma: THERAPY: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 15 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide
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
Treatment Plan Summary
DISEASE: Myeloma: THERAPY: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 16 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 70K/µL, Creatinine Clearance less
than 60 mL/min, Total Bilirubin greater than or equal to 1.5 X ULN or AST greater than or equal to 2.5 X ULN.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15,and 22 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 22 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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): lenalidomide; Refer to the Cycle 1 Day 1 take
home medications section for the following treatment medication(s): dexamethasone
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 5 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 4 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 17 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes; NOTE: Urine pregnancy test to be ordered by MD when
required.
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 with DIFF, Creatinine, Total Bilirubin, AST,
NOTE: Urine pregnancy test to be ordered by MD when required; 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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide
Follow-Up
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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 18 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide; Refer to the Cycle 1 Day 1
take home medications section for the following treatment medication(s): dexamethasone
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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide
Follow-Up
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 19 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Treatment Plan Summary
DISEASE: Myeloma: THERAPY: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+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 with DIFF, Creatinine, Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 70K/µL, Creatinine Clearance less
than 60 mL/min, Total Bilirubin greater than or equal to 1.5 X ULN or AST greater than or equal to 2.5 X ULN.
Treatment Condition A
CYCLE 2 and greater with IRREGULAR periods: Order Urine Pregnancy test every TWO weeks for females of childbearing potential
with irregular periods on Day 15,and 22 (Day 1 of next cycle);
OR CYCLE 2 and greater with REGULAR periods: Order Urine Pregnancy Test every FOUR weeks for females of childbearing
potential with regular periods on Day 22 (Day 1 of next cycle).
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 20 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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): lenalidomide; Refer to the Cycle 1 Day 1 take
home medications section for the following treatment medication(s): dexamethasone
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Take Home Medications (delete all that do not apply)
lenalidomide (REVLIMID) 5 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 10 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 15 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
lenalidomide (REVLIMID) 25 MG cap
Take by mouth one time daily for 14 days. Take Day 1 thru 14 followed by 7 days off. Total daily dose = ***mg, R-0, 1 X DAILY
starting S until S+14 or ending after 14 doses, Local Printer
Verify compliance with RevAssist program. Pharmacist will coordinate drug ordering.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes; NOTE: Urine pregnancy test to be ordered by MD when
required.
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 with DIFF, Creatinine, Total Bilirubin, AST,
NOTE: Urine pregnancy test to be ordered by MD when required; 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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 21 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide
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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide; Refer to the Cycle 1 Day 1
take home medications section for the following treatment medication(s): dexamethasone
Follow-Up
VERIFY APPOINTMENTS
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ZZtestonc,Andrew [2428787]
11/15/2016 3:41:01 PM Page 22 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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: dexamethasone 40 mg by mouth Day 1, 8 and 15, bortezomib 1.3 mg/m2 subcutaneous Day 1, 4,
8 and 11, lenalidomide 15 to 25 mg by mouth once daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: Up to 8 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients.
Note to All Staff
Note: Provider may elect to give bortezomib on Day 1 and 8 only. Provider must add treatment plan modification note and delete
Day 4 and 11 from treatment plan.
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
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 Day 1 take home medications section for the following treatment medication(s): lenalidomide
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 3:41:01 PM Page 23 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org