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/clinical/cckm-tools/content/beacon-protocols/hem---myeloma/name-96919-en.cckm

201611326

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100

UWHC,UWMF,

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

CSC HEM Melphalan(42D:1-4) Prednisone(42D:1-4) VER 10-3-16 (HL 1071)

CSC HEM Melphalan(42D:1-4) Prednisone(42D:1-4) VER 10-3-16 (HL 1071) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM MELPHALAN(28D:1-4)/PREDNISONE(28D:1-4) VER: 10-3-16 – Properties
Pre-Cycle – 11/14/2016 through 11/20/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 9 mg/m2 PO Day 1 through 4, prednisone 60 mg/m2 PO Day 1 through 4; CYCLE
LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
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
Cycle 1 – 11/21/2016 through 12/18/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
MYELOMA: Thierry, et al. Lancet 2007;370;1209-18.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 9 mg/m2 PO Day 1 through 4, prednisone 60 mg/m2 PO Day 1 through 4; CYCLE
LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/21/2016 4:19:21 PM Page 1 of 7
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
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 10.5 tabs by mouth one time daily. Take on Day 1 through 4., 105 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally).
Cycle 2 – 12/19/2016 through 1/15/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Reference Information (1)
MYELOMA: Thierry, et al. Lancet 2007;370;1209-18.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 9 mg/m2 PO Day 1 through 4, prednisone 60 mg/m2 PO Day 1 through 4; CYCLE
LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/21/2016 4:19:21 PM Page 2 of 7
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 10.5 tabs by mouth one time daily. Take on Day 1 through 4., 105 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally).
Cycle 3 – 1/16/2017 through 2/12/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/16/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Thierry, et al. Lancet 2007;370;1209-18.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 9 mg/m2 PO Day 1 through 4, prednisone 60 mg/m2 PO Day 1 through 4; CYCLE
LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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ZZtestonc,Andrew [2428787]
11/21/2016 4:19:21 PM Page 3 of 7
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to
75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 10.5 tabs by mouth one time daily. Take on Day 1 through 4., 105 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally).
Cycle 4 – 2/13/2017 through 3/12/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/13/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Thierry, et al. Lancet 2007;370;1209-18.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 9 mg/m2 PO Day 1 through 4, prednisone 60 mg/m2 PO Day 1 through 4; CYCLE
LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
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+28 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/21/2016 4:19:21 PM Page 4 of 7
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+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 10.5 tabs by mouth one time daily. Take on Day 1 through 4., 105 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally).
Cycle 5 – 3/13/2017 through 4/9/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/13/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Thierry, et al. Lancet 2007;370;1209-18.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 9 mg/m2 PO Day 1 through 4, prednisone 60 mg/m2 PO Day 1 through 4; CYCLE
LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/21/2016 4:19:21 PM Page 5 of 7
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 10.5 tabs by mouth one time daily. Take on Day 1 through 4., 105 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally).
Cycle 6 – 4/10/2017 through 5/7/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/10/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Thierry, et al. Lancet 2007;370;1209-18.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 9 mg/m2 PO Day 1 through 4, prednisone 60 mg/m2 PO Day 1 through 4; CYCLE
LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
Consent
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ZZtestonc,Andrew [2428787]
11/21/2016 4:19:21 PM Page 6 of 7
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone (dispensed Day 1 of each cycle)
and melphalan (dispensed Day 1 of each cycle)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 8 tabs by mouth one time daily. Take on Days 1 through 4., 16 mg (rounded from 16.11 mg = 9 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 10.5 tabs by mouth one time daily. Take on Day 1 through 4., 105 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally).
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ZZtestonc,Andrew [2428787]
11/21/2016 4:19:21 PM Page 7 of 7
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org