/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-96923-en.cckm

201611326

page

100

UWHC,UWMF,

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

CSC HEM Melphalan(42D:1-4) Prednisone(42D:1-4) Thalidomide(42D:1-42) VER 10-3-16 (HL 1087)

CSC HEM Melphalan(42D:1-4) Prednisone(42D:1-4) Thalidomide(42D:1-42) VER 10-3-16 (HL 1087) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM MELPHALAN(42D:1-4)/PREDNISONE(42D:1-4)/THALIDOMIDE(42D:1-42) VER: 10-3-16 – Properties
Pre-Cycle – 11/14/2016 through 11/20/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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
Take Home Medications
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
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 – 11/21/2016 through 1/1/2017 (42 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
MYELOMA: Hulin C et al. J Clin Oncol. 2009;27(22):3664-70.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 1 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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, 29, 36, 43 (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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 4., 14 mg (0.2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 14 tabs by mouth one time daily. Take on Day 1 through 4., 140 mg (2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
thalidomide (THALOMID) 50 MG cap
Take 1 cap orally at bedtime x7days then increase to 2 caps daily at bedtime, Disp-84 cap, R-0, starting S
Verify compliance with STEPS Risk Management Program. Indication: Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. NOTE: Urine Pregnancy Test to be ordered by MD when required.
DAY 43 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Day 29, Cycle 1 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients
IV Access
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 2 of 27
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
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 1/2/2017 through 2/12/2017 (42 days), Planned
Day 1, Cycle 2 – Planned for 1/2/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Hulin C et al. J Clin Oncol. 2009;27(22):3664-70.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 3 of 27
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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 4., 14 mg (0.2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 14 tabs by mouth one time daily. Take on Day 1 through 4., 140 mg (2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. NOTE: Urine Pregnancy Test to be ordered by MD when required.
DAY 43 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Day 15, Cycle 2 – Planned for 1/16/2017
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 4 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 2/13/2017 through 3/26/2017 (42 days), Planned
Day 1, Cycle 3 – Planned for 2/13/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Hulin C et al. J Clin Oncol. 2009;27(22):3664-70.
Treatment Plan Summary
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 5 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 4., 14 mg (0.2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 14 tabs by mouth one time daily. Take on Day 1 through 4., 140 mg (2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
thalidomide (THALOMID) 100 MG cap
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 6 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. NOTE: Urine Pregnancy Test to be ordered by MD when required.
DAY 43 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Day 29, Cycle 3 – Planned for 3/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 7 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 3/27/2017 through 5/7/2017 (42 days), Planned
Day 1, Cycle 4 – Planned for 3/27/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Hulin C et al. J Clin Oncol. 2009;27(22):3664-70.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 8 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 4., 14 mg (0.2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 14 tabs by mouth one time daily. Take on Day 1 through 4., 140 mg (2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. NOTE: Urine Pregnancy Test to be ordered by MD when required.
DAY 43 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Day 15, Cycle 4 – Planned for 4/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 9 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 5/8/2017 through 6/18/2017 (42 days), Planned
Day 1, Cycle 5 – Planned for 5/8/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Hulin C et al. J Clin Oncol. 2009;27(22):3664-70.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 10 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 4., 14 mg (0.2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 14 tabs by mouth one time daily. Take on Day 1 through 4., 140 mg (2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. NOTE: Urine Pregnancy Test to be ordered by MD when required.
DAY 43 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Day 29, Cycle 5 – Planned for 6/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 11 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 6/19/2017 through 7/30/2017 (42 days), Planned
Day 1, Cycle 6 – Planned for 6/19/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Hulin C et al. J Clin Oncol. 2009;27(22):3664-70.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 12 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 4., 14 mg (0.2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 14 tabs by mouth one time daily. Take on Day 1 through 4., 140 mg (2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. NOTE: Urine Pregnancy Test to be ordered by MD when required.
DAY 43 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Day 15, Cycle 6 – Planned for 7/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 13 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 7/31/2017 through 9/10/2017 (42 days), Planned
Day 1, Cycle 7 – Planned for 7/31/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Hulin C et al. J Clin Oncol. 2009;27(22):3664-70.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 14 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, 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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 4., 14 mg (0.2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 14 tabs by mouth one time daily. Take on Day 1 through 4., 140 mg (2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. NOTE: Urine Pregnancy Test to be ordered by MD when required.
DAY 43 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Day 29, Cycle 7 – Planned for 8/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 15 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 9/11/2017 through 10/22/2017 (42 days), Planned
Day 1, Cycle 8 – Planned for 9/11/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Hulin C et al. J Clin Oncol. 2009;27(22):3664-70.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 cycles;
NOTE: Thrombosis prophylaxis recommended for all patients
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 16 of 27
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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 4., 14 mg (0.2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 14 tabs by mouth one time daily. Take on Day 1 through 4., 140 mg (2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. NOTE: Urine Pregnancy Test to be ordered by MD when required.
DAY 43 FOLLOW-UP
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 17 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Day 15, Cycle 8 – Planned for 9/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 9 – 10/23/2017 through 12/3/2017 (42 days), Planned
Day 1, Cycle 9 – Planned for 10/23/2017
Treatment Plan Information
Reference Information (1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 18 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

MYELOMA: Hulin C et al. J Clin Oncol. 2009;27(22):3664-70.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 4., 14 mg (0.2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 14 tabs by mouth one time daily. Take on Day 1 through 4., 140 mg (2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 19 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. NOTE: Urine Pregnancy Test to be ordered by MD when required.
DAY 43 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Day 29, Cycle 9 – Planned for 11/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 20 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 10 – 12/4/2017 through 1/14/2018 (42 days), Planned
Day 1, Cycle 10 – Planned for 12/4/2017
Treatment Plan Information
Reference Information (1)
MYELOMA: Hulin C et al. J Clin Oncol. 2009;27(22):3664-70.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 21 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 4., 14 mg (0.2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 14 tabs by mouth one time daily. Take on Day 1 through 4., 140 mg (2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. NOTE: Urine Pregnancy Test to be ordered by MD when required.
DAY 43 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Day 15, Cycle 10 – Planned for 12/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 22 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take Home Medications
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 11 – 1/15/2018 through 2/25/2018 (42 days), Planned
Day 1, Cycle 11 – Planned for 1/15/2018
Treatment Plan Information
Reference Information (1)
MYELOMA: Hulin C et al. J Clin Oncol. 2009;27(22):3664-70.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 23 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 4., 14 mg (0.2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 14 tabs by mouth one time daily. Take on Day 1 through 4., 140 mg (2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. NOTE: Urine Pregnancy Test to be ordered by MD when required.
DAY 43 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Day 29, Cycle 11 – Planned for 2/12/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 24 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 12 – 2/26/2018 through 4/8/2018 (42 days), Planned
Day 1, Cycle 12 – Planned for 2/26/2018
Treatment Plan Information
Reference Information (1)
MYELOMA: Hulin C et al. J Clin Oncol. 2009;27(22):3664-70.
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 25 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
melphalan (ALKERAN) 2 MG tab
Take 7 tabs by mouth one time daily. Take on Days 1 through 4., 14 mg (0.2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
prednisone (DELTASONE) 10 MG tab
Take 14 tabs by mouth one time daily. Take on Day 1 through 4., 140 mg (2 mg/kg × 70 kg Treatment plan recorded weight),
R-0, 1 X DAILY starting S
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider. NOTE: Urine Pregnancy Test to be ordered by MD when required.
DAY 43 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally). NOTE:
Urine Pregnancy Test to be ordered by MD when required.
Day 15, Cycle 12 – Planned for 3/12/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myeloma; THERAPY: melphalan 0.2 mg/kg by mouth once daily Day 1 through 4, prednisone 2 mg/kg by mouth once
daily Day 1 through 4, thalidomide 100 mg by mouth once daily continuously; CYCLE LENGTH: 42 days; COURSE: 12 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
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, 29 and 43 (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 15 of even cycles and Day 1 and 29 of odd cycles.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 26 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): melphalan (dispensed Day 1 of each cycle),
prednisone (dispensed Day 1 of each cycle) and thalidomide (dispensed Day 1 and 29 of odd cycles and Day 15 of even cycles)
Take Home Medications
thalidomide (THALOMID) 100 MG cap
Take 1 cap by mouth one time daily at bedtime., 100 mg, Disp-28 cap, R-0, 1 X DAILY (HS) starting S, Local Printer
Verify compliance with STEPS Risk Management Program. Indication:Cancer treatment. Pharmacist will coordinate drug ordering.
Recommended Medication
Thrombosis Prophylaxis recommended for all patients.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/21/2016 4:21:05 PM Page 27 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org