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201611326

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CSC HEM OUTPT Bendamustine(28D:1,2) For Myeloma VER 10-3-16 (HL 4508)

CSC HEM OUTPT Bendamustine(28D:1,2) For Myeloma VER 10-3-16 (HL 4508) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM OUTPT BENDAMUSTINE(28D:1,2) FOR MYELOMA 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: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
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
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-42 tab, R-1, 1 X DAILY starting S
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily. Take continuously., 400 mg, Disp-60 tab, R-11, 2 X DAILY starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
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)
MULTIPLE MYELOMA: Michael M, et al. Eur J Med Res 2010;15:13-19.
Reference Information (2)
MULTIPLE MYELOMA: Damaj G, et al. Leuk Lymphoma 2011:epub.
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
Consent
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

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, Creatinine.
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 or serum
creatinine greater than 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Recommended Medication
Prednisone or alternative corticosteroid may be added to regimen at physician discretion.
bendamustine (BENDEKA) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine.
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), Creatinine;
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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.
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Recommended Medication
Prednisone or alternative corticosteroid may be added to regimen at physician discretion.
bendamustine (BENDEKA) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10- Lab Only, Cycle 1 – Planned for 11/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

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+8 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+8 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+8 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/19/2016 through 1/15/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
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+26 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+26 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+26 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
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 or serum
creatinine greater than 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Recommended Medication
Prednisone or alternative corticosteroid may be added to regimen at physician discretion.
bendamustine (BENDEKA) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

LABS: CBC, ANC (DIFF if to be done locally), Creatinine.
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), Creatinine;
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 2 – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Recommended Medication
Prednisone or alternative corticosteroid may be added to regimen at physician discretion.
bendamustine (BENDEKA) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10- Lab Only, Cycle 2 – Planned for 12/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
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+8 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+8 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+8 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/16/2017 through 2/12/2017 (28 days), Planned
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

Day 1, Cycle 3 – Planned for 1/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
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+26 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+26 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+26 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
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 or serum
creatinine greater than 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Recommended Medication
Prednisone or alternative corticosteroid may be added to regimen at physician discretion.
bendamustine (BENDEKA) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine.
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), Creatinine;
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
IV Access
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Recommended Medication
Prednisone or alternative corticosteroid may be added to regimen at physician discretion.
bendamustine (BENDEKA) in sodium chloride 0.9 % 50 mL bag
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10- Lab Only, Cycle 3 – Planned for 1/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
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+8 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+8 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+8 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 2/13/2017 through 3/12/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
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 4:22:50 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

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+26 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+26 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+26 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
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 or serum
creatinine greater than 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Recommended Medication
Prednisone or alternative corticosteroid may be added to regimen at physician discretion.
bendamustine (BENDEKA) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine.
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), Creatinine;
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 4 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Recommended Medication
Prednisone or alternative corticosteroid may be added to regimen at physician discretion.
bendamustine (BENDEKA) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10- Lab Only, Cycle 4 – Planned for 2/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
IV Access
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

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+8 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+8 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+8 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 3/13/2017 through 4/9/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
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+26 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+26 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+26 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
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 or serum
creatinine greater than 2 mg/dL.
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Recommended Medication
Prednisone or alternative corticosteroid may be added to regimen at physician discretion.
bendamustine (BENDEKA) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine.
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), Creatinine;
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 5 – Planned for 3/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Recommended Medication
Prednisone or alternative corticosteroid may be added to regimen at physician discretion.
bendamustine (BENDEKA) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10- Lab Only, Cycle 5 – Planned for 3/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
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+8 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+8 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+8 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

Cycle 6 – 4/10/2017 through 5/7/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
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+26 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+26 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+26 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
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 or serum
creatinine greater than 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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.
Hydration
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Recommended Medication
Prednisone or alternative corticosteroid may be added to regimen at physician discretion.
bendamustine (BENDEKA) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine.
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), Creatinine;
CHEMOTHERAPY ROOM APPOINTMENT: bendamustine for 60 minutes.
Day 2, Cycle 6 – Planned for 4/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Recommended Medication
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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

Prednisone or alternative corticosteroid may be added to regimen at physician discretion.
bendamustine (BENDEKA) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes. Hypersensitivity reaction to bendamustine can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10- Lab Only, Cycle 6 – Planned for 4/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma (Advanced); THERAPY: bendamustine 90 to 120 mg/m2 IV Days 1 and 2; CYCLE LENGTH: 28 Days;
COURSE: until disease progression; NOTE: prednisone or alternative corticosteroid may be added to regimen at physician
discretion.
Note to All Staff (1)
Monitor patients for skin reactions. Cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some fatal,
have been reported when bendamustine was administered concomitantly with allopurinol and other medications known to cause
these syndromes. Consider risk versus benefit of allopurinol prophylaxis based on tumor lysis burden and risk for tumor lysis
initiation of treatment.
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+8 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+8 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+8 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/21/2016 4:22:50 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