/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-96562-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 Temozolomide(28D:1-14 OR 1-21) VER 9-13-17 (HL 990)

CSC Brain Temozolomide(28D:1-14 OR 1-21) VER 9-13-17 (HL 990) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Brain


CSC BRAIN TEMOZOLOMIDE(28D:1-14 OR 1-21) 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: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth 1 hour before temozolomide for first 7 days then 1/2-1 tab every 8 hours as needed., Disp-30
tab, R-5, starting S
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)
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 1 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

GLIOMA: Reardon DA, et al. J Clin Oncol 2006;24(8):1253-65.
Reference Information (2)
GLIOMA: Quinn J, et al. J Clin Onc 2013;21(4):646-51.
Reference Information (3)
GLIOMA: Pace A, et al. Ann Oncol 2003;14(21):1722-26.
Reference Information (4)
GLIOMA: Kesari S, et al. Clin Cancer Res 2009;15:330-7.
Reference Information (5)
GLIOMA: Tolcher AW, et al. Br J Cancer 2003;88(7):1004-11.
Treatment Plan Summary
DISEASE: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 2 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 3 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

DAY 15 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
Day 15 - Lab Only, Cycle 1 –  Planned for 11/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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+14 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  12/11/2017 through 1/7/2018 (28 days), Planned
Day 1, Cycle 2 –  Planned for 12/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Consent
Verify Consent
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 4 of 44
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 5 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
Cycle 3 –  1/8/2018 through 2/4/2018 (28 days), Planned
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 6 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Day 1, Cycle 3 –  Planned for 1/8/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 7 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
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): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 8 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
Cycle 4 –  2/5/2018 through 3/4/2018 (28 days), Planned
Day 1, Cycle 4 –  Planned for 2/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 9 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
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): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 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...
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 10 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily
dose = *** mg, R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on
*** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
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: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 11 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@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.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 12 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
Cycle 6 –  4/2/2018 through 4/29/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 4/2/2018
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 13 of 44
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: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 14 of 44
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.
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): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 15 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily
dose = *** mg, R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on
*** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
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: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 16 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
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): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 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...
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 17 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
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: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 18 of 44
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 19 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
Cycle 9 –  6/25/2018 through 7/22/2018 (28 days), Planned
Day 1, Cycle 9 –  Planned for 6/25/2018
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 20 of 44
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: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 21 of 44
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.
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): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 22 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily
dose = *** mg, R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on
*** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
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: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 23 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
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): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 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...
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 24 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
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: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 25 of 44
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 26 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
Cycle 12 –  9/17/2018 through 10/14/2018 (28 days), Planned
Day 1, Cycle 12 –  Planned for 9/17/2018
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 27 of 44
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: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 28 of 44
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.
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): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 29 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily
dose = *** mg, R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on
*** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
Cycle 13 –  10/15/2018 through 11/11/2018 (28 days), Planned
Day 1, Cycle 13 –  Planned for 10/15/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 30 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
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): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 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...
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 31 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
Cycle 14 –  11/12/2018 through 12/9/2018 (28 days), Planned
Day 1, Cycle 14 –  Planned for 11/12/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 32 of 44
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 33 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
Cycle 15 –  12/10/2018 through 1/6/2019 (28 days), Planned
Day 1, Cycle 15 –  Planned for 12/10/2018
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 34 of 44
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: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 35 of 44
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.
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): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 36 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily
dose = *** mg, R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on
*** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
Cycle 16 –  1/7/2019 through 2/3/2019 (28 days), Planned
Day 1, Cycle 16 –  Planned for 1/7/2019
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 37 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
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): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 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...
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 38 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
Cycle 17 –  2/4/2019 through 3/3/2019 (28 days), Planned
Day 1, Cycle 17 –  Planned for 2/4/2019
Treatment Plan Information
Treatment Plan Summary
DISEASE: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 39 of 44
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 40 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
Cycle 18 –  3/4/2019 through 3/31/2019 (28 days), Planned
Day 1, Cycle 18 –  Planned for 3/4/2019
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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 41 of 44
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: Relapsed Glioma (Advanced); THERAPY: temozolomide 75 to 100 mg/m2 by mouth daily on Days 1 through
14 or Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: up to 18 cycles.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
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
Pre-Labs (delete all that do not apply)
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Platelets less than or equal to 105K/µL or ANC less than or equal
to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to initiate Zoster and Pneumocystis Carinii prophylaxis for Absolute Lymphocyte Count
less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 42 of 44
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.
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): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily dose = *** mg,
R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 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...
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 43 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take  by mouth one time daily. Take Day *** thru *** . Swallow whole on empty stomach. Total daily
dose = *** mg, R-0, 1 X DAILY starting S
Indicate in sig if therapy is for 14 or 21 days. Round dose to available capsule sizes. Dosing based on
*** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF.
LABS (Every other cycle): AST, ALT, Total Bilirubin, Alkaline Phosphatase; RADIOLOGY: MRI.
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
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:27:58 AM Page 44 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org