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/clinical/cckm-tools/content/beacon-protocols/brain/name-96563-en.cckm

201711317

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100

UWHC,UWMF,

Tools,

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

CSC Brain Temozolomide(28D:1-21) VER 9-13-17 (HL 4344)

CSC Brain Temozolomide(28D:1-21) VER 9-13-17 (HL 4344) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Brain


CSC BRAIN TEMOZOLOMIDE(28D: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: Pituitary Tumors/Carcinoma refractory to surgery and/or radiation (Advanced): THERAPY: temozolomide 75
mg/m2 by mouth one time daily Day 1 through 21, followed by 7 days off; CYCLE LENGTH: 28 days; COURSE: until
disease progression.
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)
PITUITARY TUMORS: Bush ZM, et al. J Clin Endocrinol Metab 2010;95(11):E280-90.
Reference Information (2)
PITUITARY TUMORS: Raverot G, et al. J Clin Endocrinol Metab 2010;95(10):4592-9.
Treatment Plan Summary
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:40:48 AM Page 1 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

DISEASE: Pituitary Tumors/Carcinoma refractory to surgery and/or radiation (Advanced): THERAPY:
temozolomide 75 mg/m2 by mouth one time daily Day 1 through 21, followed by 7 days off; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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.
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) 180 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
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Zztestonc,Fiona F [2462287]
11/13/2017 10:40:48 AM Page 2 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

temozolomide (TEMODAR) 140 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 22 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.
Lab Only - Day 22, Cycle 1 –  Planned for 12/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pituitary Tumors/Carcinoma refractory to surgery and/or radiation (Advanced): THERAPY: temozolomide 75
mg/m2 by mouth one time daily Day 1 through 21, followed by 7 days off; CYCLE LENGTH: 28 days; COURSE: until
disease progression.
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+21 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
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Zztestonc,Fiona F [2462287]
11/13/2017 10:40:48 AM Page 3 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Pituitary Tumors/Carcinoma refractory to surgery and/or radiation (Advanced): THERAPY:
temozolomide 75 mg/m2 by mouth one time daily Day 1 through 21, followed by 7 days off; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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)
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.
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Zztestonc,Fiona F [2462287]
11/13/2017 10:40:48 AM Page 4 of 13
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) 180 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
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
Day 1, Cycle 3 –  Planned for 1/8/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pituitary Tumors/Carcinoma refractory to surgery and/or radiation (Advanced): THERAPY: temozolomide 75
mg/m2 by mouth one time daily Day 1 through 21, followed by 7 days off; CYCLE LENGTH: 28 days; COURSE: until
disease progression.
Consent
Verify Consent
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Zztestonc,Fiona F [2462287]
11/13/2017 10:40:48 AM Page 5 of 13
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.
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Zztestonc,Fiona F [2462287]
11/13/2017 10:40:48 AM Page 6 of 13
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) 180 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
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: Pituitary Tumors/Carcinoma refractory to surgery and/or radiation (Advanced): THERAPY: temozolomide 75
mg/m2 by mouth one time daily Day 1 through 21, followed by 7 days off; CYCLE LENGTH: 28 days; COURSE: until
disease progression.
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.
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Zztestonc,Fiona F [2462287]
11/13/2017 10:40:48 AM Page 7 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
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)
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)
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Zztestonc,Fiona F [2462287]
11/13/2017 10:40:48 AM Page 8 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

temozolomide (TEMODAR) 180 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total
daily dose = *** mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
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: Pituitary Tumors/Carcinoma refractory to surgery and/or radiation (Advanced): THERAPY: temozolomide 75
mg/m2 by mouth one time daily Day 1 through 21, followed by 7 days off; CYCLE LENGTH: 28 days; COURSE: until
disease progression.
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
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Zztestonc,Fiona F [2462287]
11/13/2017 10:40:48 AM Page 9 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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)
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) 180 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
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Zztestonc,Fiona F [2462287]
11/13/2017 10:40:48 AM Page 10 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
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
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pituitary Tumors/Carcinoma refractory to surgery and/or radiation (Advanced): THERAPY: temozolomide 75
mg/m2 by mouth one time daily Day 1 through 21, followed by 7 days off; CYCLE LENGTH: 28 days; COURSE: until
disease progression.
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
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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)
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) 180 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
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Zztestonc,Fiona F [2462287]
11/13/2017 10:40:48 AM Page 12 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

temozolomide (TEMODAR) 20 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total
daily dose = *** mg, R-0, starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take *** caps by mouth at bedtime on Days *** thru ***. Swallow whole on empty stomach. Total daily dose = ***
mg, R-0, starting S, Local Printer
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.
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Zztestonc,Fiona F [2462287]
11/13/2017 10:40:48 AM Page 13 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org