/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/brain/,

/clinical/cckm-tools/content/beacon-protocols/brain/name-96559-en.cckm

201711317

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Brain

CSC Brain Lomustine(28D:1) VER 9-13-17 (HL 987)

CSC Brain Lomustine(28D:1) VER 9-13-17 (HL 987) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Brain


CSC BRAIN LOMUSTINE(28D:1) VER: 9-13-17 –  Properties
Pre-Cycle –  11/6/2017 through 11/12/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 11/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tablet 1 hour prior to lomustine and 1 tablet every 8 hours as needed. Max 3 tabs in 24 hours., Disp-30 tab,
R-5, starting S
lorazepam (ATIVAN) 1 MG tab
Take 1 tab by mouth once at bedtime. Take with lomustine dose., 1 mg, Disp-6 tab, R-6, ONCE (HS) starting S, Local
Printer
Cycle 1 –  11/13/2017 through 12/10/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 11/13/2017
Treatment Plan Information
Reference Information (1)
GLIOMA: Prados MD, et al. J Clin Oncol 1999;17:3389-95.
Treatment Plan Summary
DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
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
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 1 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(2)
Verify patient has taken ondansetron 8 mg by mouth prior to lomustine.
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): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 2 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Cycle 2 –  12/11/2017 through 1/7/2018 (28 days), Planned
Day 1, Cycle 2 –  Planned for 12/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
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+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(2)
Verify patient has taken ondansetron 8 mg by mouth prior to lomustine.
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): lomustine (Dispensed on Day 1
of each cycle)
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 3 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take Home Medications (delete all that do not apply)
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
Cycle 3 –  1/8/2018 through 2/4/2018 (28 days), Planned
Day 1, Cycle 3 –  Planned for 1/8/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
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+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 4 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(2)
Verify patient has taken ondansetron 8 mg by mouth prior to lomustine.
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): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
Cycle 4 –  2/5/2018 through 3/4/2018 (28 days), Planned
Day 1, Cycle 4 –  Planned for 2/5/2018
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 5 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
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+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(2)
Verify patient has taken ondansetron 8 mg by mouth prior to lomustine.
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): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 100 MG cap
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 6 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
Cycle 5 –  3/5/2018 through 4/1/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 3/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
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+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
Actions
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 7 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(2)
Verify patient has taken ondansetron 8 mg by mouth prior to lomustine.
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): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
Cycle 6 –  4/2/2018 through 4/29/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 4/2/2018
Treatment Plan Information
Treatment Plan Summary
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
Actions
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 8 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
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+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(2)
Verify patient has taken ondansetron 8 mg by mouth prior to lomustine.
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): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 9 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
Cycle 7 –  4/30/2018 through 5/27/2018 (28 days), Planned
Day 1, Cycle 7 –  Planned for 4/30/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
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+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(2)
Verify patient has taken ondansetron 8 mg by mouth prior to lomustine.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 10 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
Cycle 8 –  5/28/2018 through 6/24/2018 (28 days), Planned
Day 1, Cycle 8 –  Planned for 5/28/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
Consent
Verify Consent
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 11 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(2)
Verify patient has taken ondansetron 8 mg by mouth prior to lomustine.
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): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 12 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
Cycle 9 –  6/25/2018 through 7/22/2018 (28 days), Planned
Day 1, Cycle 9 –  Planned for 6/25/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
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+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(2)
Verify patient has taken ondansetron 8 mg by mouth prior to lomustine.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 13 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
Cycle 10 –  7/23/2018 through 8/19/2018 (28 days), Planned
Day 1, Cycle 10 –  Planned for 7/23/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
Actions
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 14 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@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 WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(2)
Verify patient has taken ondansetron 8 mg by mouth prior to lomustine.
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): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 10 MG cap
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 15 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
Cycle 11 –  8/20/2018 through 9/16/2018 (28 days), Planned
Day 1, Cycle 11 –  Planned for 8/20/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
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+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(2)
Verify patient has taken ondansetron 8 mg by mouth prior to lomustine.
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
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 16 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
Cycle 12 –  9/17/2018 through 10/14/2018 (28 days), Planned
Day 1, Cycle 12 –  Planned for 9/17/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapse Glioma (Advanced); THERAPY: lomustine 70 mg/m2 by mouth Day 1; CYCLE LENGTH: 28 days;
COURSE: up to 12 cycles.
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.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
Actions
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 17 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(2)
Verify patient has taken ondansetron 8 mg by mouth prior to lomustine.
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): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once. Take on Day 1. Take on empty stomach., 70 mg/m2, R-0, ONCE starting S until S
Round dose to available capsule size.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 18 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:21:53 AM Page 19 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org