/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-96922-en.cckm

201611320

page

100

UWHC,UWMF,

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:1-4,9-12) Thalidomide(21D:1-21) VER 10-3-16 (HL 1091)

CSC HEM Bortezomib(21D:1,4,8,11) Dexamethasone(21D:1-4,9-12) Thalidomide(21D:1-21) VER 10-3-16 (HL 1091) - 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:1-4,9-12)/THALIDOMIDE(21D:1-21) VER:10-3-16 – Properties
Pre-Cycle – 11/8/2016 through 11/14/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/8/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 1 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
MYELOMA: Ludwig H et al. J Clin Oncol. 2013;31(2):247-55.
Reference Information (2)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
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.
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
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and thalidomide (dispensed Day 1 of each cycle)
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
thalidomide (THALOMID) 50 MG cap
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 2 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take 1 cap orally at bedtime x7days then increase to 2 caps daily at bedtime, Disp-56 cap, R-0, starting S
Verify compliance with STEPS Risk Management Program. Indication: Cancer treatment. Pharmacist will
coordinate drug ordering.
Take Home Medications (delete all that do not apply)
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 1, 2, 3, 4, 9, 10, 11, 12., 40 mg, Disp-80 tab, R-1, 1 X DAILY starting S, Local
Printer
Day 1 may be given in clinic.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 2, 3, 9, 10, 12., 40 mg, Disp-50 tab, R-1, 1 X DAILY starting S, Local Printer
Day 1, 4 and 11 will be given in clinic.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT:
bortezomib for 30 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Day 4, Cycle 1 – Planned for 11/18/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken thalidomide and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 3 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken thalidomide and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 1 – Planned for 11/25/2016
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 4 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken thalidomide and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/6/2016 through 12/26/2016 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/6/2016
Treatment Plan Information
Reference Information (1)
MYELOMA: Ludwig H et al. J Clin Oncol. 2013;31(2):247-55.
Reference Information (2)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 5 of 18
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+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.33 mg
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 6 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and thalidomide (dispensed Day 1 of each cycle)
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
thalidomide (THALOMID) 50 MG cap
Take 2 caps by mouth one time daily at bedtime., 100 mg, Disp-56 cap, R-0, 1 X DAILY (HS) starting S
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Take Home Medications (delete all that do not apply)
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 1, 2, 3, 4, 9, 10, 11, 12., 40 mg, Disp-80 tab, R-1, 1 X DAILY starting S, Local
Printer
Day 1 may be given in clinic.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 2, 3, 9, 10, 12., 40 mg, Disp-50 tab, R-1, 1 X DAILY starting S, Local Printer
Day 1, 4 and 11 will be given in clinic.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT:
bortezomib for 30 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Day 4, Cycle 2 – Planned for 12/9/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken thalidomide and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 7 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 2 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken thalidomide and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 8 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 2 – Planned for 12/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken thalidomide and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 12/27/2016 through 1/16/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 12/27/2016
Treatment Plan Information
Reference Information (1)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 9 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

MYELOMA: Ludwig H et al. J Clin Oncol. 2013;31(2):247-55.
Reference Information (2)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 10 of 18
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.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and thalidomide (dispensed Day 1 of each cycle)
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
thalidomide (THALOMID) 50 MG cap
Take 2 caps by mouth one time daily at bedtime., 100 mg, Disp-56 cap, R-0, 1 X DAILY (HS) starting S
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Take Home Medications (delete all that do not apply)
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 1, 2, 3, 4, 9, 10, 11, 12., 40 mg, Disp-80 tab, R-1, 1 X DAILY starting S, Local
Printer
Day 1 may be given in clinic.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 2, 3, 9, 10, 12., 40 mg, Disp-50 tab, R-1, 1 X DAILY starting S, Local Printer
Day 1, 4 and 11 will be given in clinic.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT:
bortezomib for 30 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Day 4, Cycle 3 – Planned for 12/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 11 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify that patient has taken thalidomide and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 3 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken thalidomide and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 12 of 18
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 3 – Planned for 1/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken thalidomide and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 13 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 4 – 1/17/2017 through 2/6/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/17/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Ludwig H et al. J Clin Oncol. 2013;31(2):247-55.
Reference Information (2)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+11 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+11 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+11 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 14 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): dexamethasone (dispensed Day 1 of each
cycle) and thalidomide (dispensed Day 1 of each cycle)
Take Home Medications
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
thalidomide (THALOMID) 50 MG cap
Take 2 caps by mouth one time daily at bedtime., 100 mg, Disp-56 cap, R-0, 1 X DAILY (HS) starting S
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Take Home Medications (delete all that do not apply)
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 1, 2, 3, 4, 9, 10, 11, 12., 40 mg, Disp-80 tab, R-1, 1 X DAILY starting S, Local
Printer
Day 1 may be given in clinic.
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 2, 3, 9, 10, 12., 40 mg, Disp-50 tab, R-1, 1 X DAILY starting S, Local Printer
Day 1, 4 and 11 will be given in clinic.
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT:
bortezomib for 30 minutes. NOTE: Urine Pregnancy Test to be ordered by MD when required.
Day 4, Cycle 4 – Planned for 1/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 15 of 18
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.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken thalidomide and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 4 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken thalidomide and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 16 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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
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: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8 and 11, dexamethasone 40 mg by mouth Day 1
through 4 and 9 through 12, thalidomide 100 mg by mouth once daily continously; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: Thrombosis prophylaxis recommended for all patients.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken thalidomide and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 17 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

bortezomib (VELCADE) subcutaneous injection 2.33 mg
2.33 mg (rounded from 2.327 mg = 1.3 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:36:39 PM Page 18 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org