/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-96924-en.cckm

201704114

page

100

UWHC,UWMF,

Tools,

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

CSC HEM C1 Bortez(21D1,4,8,11) C2&3 Bortez Dex Ritux(35D1,8,15,22) C3&4 Bortez(35D1,8,15,22) VER 4-24-17 (HL 4339)

CSC HEM C1 Bortez(21D1,4,8,11) C2&3 Bortez Dex Ritux(35D1,8,15,22) C3&4 Bortez(35D1,8,15,22) VER 4-24-17 (HL 4339) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM C1:BORTEZ(21D:1,4,8,11)/C2&5:BORTEZ/DEX/RITUX(35D:1,8,15,22)/C3&4: BORTEZ(35D:1,8,15,22) VER: 4-24-
17 – Properties
Pre-Cycle – 4/17/2017 through 4/23/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 4/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
IMMUNOGLOBULINS A,G,M
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS C AB
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B CORE AB, TOTAL
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AG
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AB
Expected-S Approximate, Expires-S+122, Routine
Pre-Labs (delete all that do not apply)
HEPATITIS B DNA, ULTRA QUANT, PCR
Expected-S Approximate, Expires-S+122, Routine
Draw if Hepatitis B Core AB is positive.
Take Home Medications
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 1 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
Cycle 1 - Bortezomib – 4/24/2017 through 5/14/2017 (21 days), Planned
Day 1, Cycle 1 - Bortezomib – Planned for 4/24/2017
Treatment Plan Information
Reference Information (1)
WALDENSTROM MACROGLOBULINEMIA: Dimopoulos M, et al. Blood 2013;122(19):3276-82
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
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 with DIFF, IgM.
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 Parameters (2)
Notify authorizing prescriber for IgM greater than 5000 mg/dL. IgM levels will be monitored for potential rituximab induced
complications (hyperviscosity or IgM flare).
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.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 2 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
Take Home Medications
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
Follow-Up
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 60 minutes.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 60 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, BUN, Creatinine, Total
Bilirubin, AST and IgM; CHEMOTHERAPY ROOM APPOINTMENT: dexamethasone, rituximab and bortezomib for 120 minutes.
Day 4, Cycle 1 - Bortezomib – Planned for 4/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 3 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, 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 - Bortezomib – Planned for 5/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, 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 - Bortezomib – Planned for 5/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 4 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@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.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 1.3 mg/m2 (Treatment Plan)
1.3 mg/m2, 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 - Dexamethasone, Rituximab, Bortezomib – 5/15/2017 through 6/18/2017 (35 days), Planned
Day 1, Cycle 2 - Dexamethasone, Rituximab, Bortezomib – Planned for 5/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 5 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
BUN
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Routine
IMMUNOGLOBULIN M
Expected-S+10, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, IgM.
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 Parameters (2)
Notify authorizing prescriber for IgM greater than 5000 mg/dL. IgM levels will be monitored for potential rituximab induced
complications (hyperviscosity or IgM flare).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 6 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, ONCE, 1 dose Starting when released
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient experiences fever accompanied by
chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the patient returns to baseline, infusion may be
restarted at half the rate during which the reaction occurred.
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: dexamethasone, rituximab and bortezomib for 120 minutes.
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: dexamethasone, rituximab and bortezomib for 120 minutes.
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: dexamethasone, rituximab and bortezomib for 120 minutes.
DAY 36 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, BUN, Creatinine, Total
Bilirubin, AST and IgM; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 60 minutes.
Day 8, Cycle 2 - Dexamethasone, Rituximab, Bortezomib – Planned for 5/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
IV Access
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 7 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, ONCE, 1 dose Starting when released
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 8 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than
6 months since last dose. For first and second dose patient should be treated in a location to optimize emergency
care. See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates.
If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction
occurred.
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, 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 15, Cycle 2 - Dexamethasone, Rituximab, Bortezomib – Planned for 5/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 9 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, ONCE, 1 dose Starting when released
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient experiences fever accompanied by
chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the patient returns to baseline, infusion may be
restarted at half the rate during which the reaction occurred.
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, 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 22, Cycle 2 - Dexamethasone, Rituximab, Bortezomib – Planned for 6/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 10 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, ONCE, 1 dose Starting when released
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 11 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient experiences fever accompanied by
chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the patient returns to baseline, infusion may be
restarted at half the rate during which the reaction occurred.
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, 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 - Bortezomib – 6/19/2017 through 7/23/2017 (35 days), Planned
Day 1, Cycle 3 - Bortezomib – Planned for 6/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+13 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+13 Approximate, Expires-S+365, Routine
BUN
Expected-S+13 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+13 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+13 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+13 Approximate, Expires-S+365, Routine
IMMUNOGLOBULIN M
Expected-S+13, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, IgM.
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 Parameters (2)
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 12 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Notify authorizing prescriber for IgM greater than 5000 mg/dL. IgM levels will be monitored for potential rituximab induced
complications (hyperviscosity or IgM flare).
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 60 minutes.
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 60 minutes.
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 60 minutes.
DAY 36 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, BUN, Creatinine, Total
Bilirubin, AST and IgM; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 60 minutes.
Day 8, Cycle 3 - Bortezomib – Planned for 6/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 13 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, 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 15, Cycle 3 - Bortezomib – Planned for 7/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
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.
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.
Hydration
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 14 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, 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 22, Cycle 3 - Bortezomib – Planned for 7/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
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.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, 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,Greg G [2487509]
4/24/2017 9:41:26 AM Page 15 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Cycle 4 - Bortezomib – 7/24/2017 through 8/27/2017 (35 days), Planned
Day 1, Cycle 4 - Bortezomib – Planned for 7/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+13 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+13 Approximate, Expires-S+365, Routine
BUN
Expected-S+13 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+13 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+13 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+13 Approximate, Expires-S+365, Routine
IMMUNOGLOBULIN M
Expected-S+13, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, IgM.
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 Parameters (2)
Notify authorizing prescriber for IgM greater than 5000 mg/dL. IgM levels will be monitored for potential rituximab induced
complications (hyperviscosity or IgM flare).
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
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 16 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 60 minutes.
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 60 minutes.
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 60 minutes.
DAY 36 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, BUN, Creatinine, Total
Bilirubin, AST and IgM; CHEMOTHERAPY ROOM APPOINTMENT: dexamethasone, rituximab and bortezomib for 120 minutes.
Day 8, Cycle 4 - Bortezomib – Planned for 7/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
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.
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.
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 17 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, 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 15, Cycle 4 - Bortezomib – Planned for 8/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
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.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, 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,Greg G [2487509]
4/24/2017 9:41:26 AM Page 18 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Day 22, Cycle 4 - Bortezomib – Planned for 8/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
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.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, 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 5 - Dexamethasone, Rituximab, Bortezomib – 8/28/2017 through 10/1/2017 (35 days), Planned
Day 1, Cycle 5 - Dexamethasone, Rituximab, Bortezomib – Planned for 8/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 19 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+13 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+13 Approximate, Expires-S+365, Routine
BUN
Expected-S+13 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+13 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+13 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+13 Approximate, Expires-S+365, Routine
IMMUNOGLOBULIN M
Expected-S+13, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, IgM.
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 Parameters (2)
Notify authorizing prescriber for IgM greater than 5000 mg/dL. IgM levels will be monitored for potential rituximab induced
complications (hyperviscosity or IgM flare).
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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.
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 20 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, ONCE, 1 dose Starting when released
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient experiences fever accompanied by
chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the patient returns to baseline, infusion may be
restarted at half the rate during which the reaction occurred.
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, Subcutaneous, ONCE, 1 dose Starting when released
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: dexamethasone, rituximab and bortezomib for 120 minutes.
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: dexamethasone, rituximab and bortezomib for 120 minutes.
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: dexamethasone, rituximab and bortezomib for 120 minutes.
DAY 36 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, BUN, Creatinine, Total
Bilirubin, AST and IgM; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 60 minutes.
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 21 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Day 8, Cycle 5 - Dexamethasone, Rituximab, Bortezomib – Planned for 9/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 22 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, ONCE, 1 dose Starting when released
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient experiences fever accompanied by
chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the patient returns to baseline, infusion may be
restarted at half the rate during which the reaction occurred.
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, 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 15, Cycle 5 - Dexamethasone, Rituximab, Bortezomib – Planned for 9/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15, and 22,
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
COURSE: 5 cycles total.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
Flush Venous Access Device per Guidelines
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 23 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, ONCE, 1 dose Starting when released
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient experiences fever accompanied by
chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the patient returns to baseline, infusion may be
restarted at half the rate during which the reaction occurred.
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, 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 22, Cycle 5 - Dexamethasone, Rituximab, Bortezomib – Planned for 9/18/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 24 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

DISEASE: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma;
THERAPY: CYCLE 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11; CYCLE LENGTH: 21 days;
THERAPY: CYCLES 2 and 5: dexamethasone 40 mg IV Day 1, 8, 15 and 22, rituximab 375 mg/m2 IV Day 1, 8, 15,
and 22, bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35 days;
THERAPY: CYCLES 3 and 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22; CYCLE LENGTH: 35
days;
COURSE: 5 cycles total.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
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Zztestonc,Greg G [2487509]
4/24/2017 9:41:26 AM Page 25 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, ONCE, 1 dose Starting when released
rituximab (RITUXAN) 375 mg/m2 in sodium chloride 0.9 % 500 mL bag
375 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient experiences fever accompanied by
chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the patient returns to baseline, infusion may be
restarted at half the rate during which the reaction occurred.
bortezomib (VELCADE) subcutaneous injection 1.6 mg/m2 (Treatment Plan)
1.6 mg/m2, 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,Greg G [2487509]
4/24/2017 9:41:26 AM Page 26 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org