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

/clinical/cckm-tools/content/beacon-protocols/breast/name-96596-en.cckm

201611306

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100

UWHC,UWMF,

Tools,

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

CSC Breast Capecitabine (21D1-14 Oral), Gemcitabine (21D1,8) VER 10-3-16 (HL 564)

CSC Breast Capecitabine (21D1-14 Oral), Gemcitabine (21D1,8) VER 10-3-16 (HL 564) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST CAPECITABINE(21D:1-14 ORAL)/GEMCITABINE(21D:1,8) VER: 10-3-16 – Properties
Pre-Cycle – 10/25/2016 through 10/31/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 10/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 11/1/2016 through 11/21/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/1/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Sikov WM, et al. J Clin Oncol 2005;23:785.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 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 and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 1 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than 75K/µL or
Creatinine greater than ULN or Total Bilirubin greater than or equal to 1.6 mg/dL or AST greater than or equal to 5X
ULN.
Dose Modification for Oral Chemotherapy
Contact MD if gemcitabine dose held or reduced to discuss capecitabine dose modification.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,000 mg/m2 in sodium chloride 0.9 % 100 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 830 mg/m2 by mouth 2 times daily. Take on Day 1 (PM) through Day 15 (AM)., 830 mg/m2, R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
capecitabine (XELODA) 150 MG tab
Take 830 mg/m2 by mouth 2 times daily. Take on Day 1 (PM) through Day 15 (AM)., 830 mg/m2, R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
Day 8, Cycle 1 – Planned for 11/8/2016
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 2 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 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 WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than 75K/µL.
Dose Modification for Oral Chemotherapy
Contact MD if gemcitabine dose held or reduced to discuss capecitabine dose modification.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,000 mg/m2 in sodium chloride 0.9 % 100 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 3 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 11/22/2016 through 12/12/2016 (21 days), Planned
Day 1, Cycle 2 – Planned for 11/22/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Sikov WM, et al. J Clin Oncol 2005;23:785.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than 75K/µL or Creatinine greater than
ULN or Total Bilirubin greater than or equal to 1.6 mg/dL or AST greater than or equal to 5X ULN.
Dose Modification for Oral Chemotherapy
Contact MD if gemcitabine dose held or reduced to discuss capecitabine dose modification.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
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 10 UNIT/ML lock flush injection 1-150 units
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 4 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,000 mg/m2 in sodium chloride 0.9 % 100 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 830 mg/m2 by mouth 2 times daily. Take on Day 1 (PM) through Day 15 (AM)., 830 mg/m2, R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
capecitabine (XELODA) 150 MG tab
Take 830 mg/m2 by mouth 2 times daily. Take on Day 1 (PM) through Day 15 (AM)., 830 mg/m2, R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
Day 8, Cycle 2 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 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 WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 5 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than 75K/µL.
Dose Modification for Oral Chemotherapy
Contact MD if gemcitabine dose held or reduced to discuss capecitabine dose modification.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,000 mg/m2 in sodium chloride 0.9 % 100 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 12/13/2016 through 1/2/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 12/13/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Sikov WM, et al. J Clin Oncol 2005;23:785.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 6 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than 75K/µL or Creatinine greater than
ULN or Total Bilirubin greater than or equal to 1.6 mg/dL or AST greater than or equal to 5X ULN.
Dose Modification for Oral Chemotherapy
Contact MD if gemcitabine dose held or reduced to discuss capecitabine dose modification.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,000 mg/m2 in sodium chloride 0.9 % 100 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 7 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 830 mg/m2 by mouth 2 times daily. Take on Day 1 (PM) through Day 15 (AM)., 830 mg/m2, R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
capecitabine (XELODA) 150 MG tab
Take 830 mg/m2 by mouth 2 times daily. Take on Day 1 (PM) through Day 15 (AM)., 830 mg/m2, R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
Day 8, Cycle 3 – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 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 WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than 75K/µL.
Dose Modification for Oral Chemotherapy
Contact MD if gemcitabine dose held or reduced to discuss capecitabine dose modification.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
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,Andrew [2428787]
11/1/2016 3:04:11 PM Page 8 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,000 mg/m2 in sodium chloride 0.9 % 100 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 1/3/2017 through 1/23/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/3/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Sikov WM, et al. J Clin Oncol 2005;23:785.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 9 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than 75K/µL or
Creatinine greater than ULN or Total Bilirubin greater than or equal to 1.6 mg/dL or AST greater than or equal to 5X
ULN.
Dose Modification for Oral Chemotherapy
Contact MD if gemcitabine dose held or reduced to discuss capecitabine dose modification.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,000 mg/m2 in sodium chloride 0.9 % 100 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 830 mg/m2 by mouth 2 times daily. Take on Day 1 (PM) through Day 15 (AM)., 830 mg/m2, R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
capecitabine (XELODA) 150 MG tab
Take 830 mg/m2 by mouth 2 times daily. Take on Day 1 (PM) through Day 15 (AM)., 830 mg/m2, R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 10 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 8, Cycle 4 – Planned for 1/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 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 WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than 75K/µL.
Dose Modification for Oral Chemotherapy
Contact MD if gemcitabine dose held or reduced to discuss capecitabine dose modification.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,000 mg/m2 in sodium chloride 0.9 % 100 mL bag
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 11 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 1/24/2017 through 2/13/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 1/24/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Sikov WM, et al. J Clin Oncol 2005;23:785.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than 75K/µL or Creatinine greater than
ULN or Total Bilirubin greater than or equal to 1.6 mg/dL or AST greater than or equal to 5X ULN.
Dose Modification for Oral Chemotherapy
Contact MD if gemcitabine dose held or reduced to discuss capecitabine dose modification.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
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,Andrew [2428787]
11/1/2016 3:04:11 PM Page 12 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,000 mg/m2 in sodium chloride 0.9 % 100 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 830 mg/m2 by mouth 2 times daily. Take on Day 1 (PM) through Day 15 (AM)., 830 mg/m2, R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
capecitabine (XELODA) 150 MG tab
Take 830 mg/m2 by mouth 2 times daily. Take on Day 1 (PM) through Day 15 (AM)., 830 mg/m2, R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
Day 8, Cycle 5 – Planned for 1/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 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 WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 13 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than 75K/µL.
Dose Modification for Oral Chemotherapy
Contact MD if gemcitabine dose held or reduced to discuss capecitabine dose modification.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,000 mg/m2 in sodium chloride 0.9 % 100 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 2/14/2017 through 3/6/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 2/14/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Sikov WM, et al. J Clin Oncol 2005;23:785.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 14 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than 75K/µL or Creatinine greater than
ULN or Total Bilirubin greater than or equal to 1.6 mg/dL or AST greater than or equal to 5X ULN.
Dose Modification for Oral Chemotherapy
Contact MD if gemcitabine dose held or reduced to discuss capecitabine dose modification.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,000 mg/m2 in sodium chloride 0.9 % 100 mL bag
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 15 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 830 mg/m2 by mouth 2 times daily. Take on Day 1 (PM) through Day 15 (AM)., 830 mg/m2, R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
capecitabine (XELODA) 150 MG tab
Take 830 mg/m2 by mouth 2 times daily. Take on Day 1 (PM) through Day 15 (AM)., 830 mg/m2, R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
Day 8, Cycle 6 – Planned for 2/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1 and 8, capecitabine 830 mg/m2 by mouth
twice daily Days 1 through 14; CYCLE LENGTH: 21 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 WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than 75K/µL.
Dose Modification for Oral Chemotherapy
Contact MD if gemcitabine dose held or reduced to discuss capecitabine dose modification.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 16 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,000 mg/m2 in sodium chloride 0.9 % 100 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:04:11 PM Page 17 of 17
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org