/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-96623-en.cckm

201611306

page

100

UWHC,UWMF,

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

CSC Breast Cyclophosphamide(21D1) Fluorouracil(21D1) Methotrexate(21D1) VER: 10-3-16 (HL 1806)

CSC Breast Cyclophosphamide(21D1) Fluorouracil(21D1) Methotrexate(21D1) VER: 10-3-16 (HL 1806) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST CYCLOPHOSPHAMIDE(21D:1)/FLUOROURACIL(21D:1)/METHOTREXATE(21D:1) 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 (Advanced/Adjuvant); THERAPY: methotrexate 40 mg/m2 IV Day 1, fluorouracil 600 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days. COURSE: 8 cycles or 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
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
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: Bonadonna G, et al. BMJ 2005;330(7485):217.
Reference Information (2)
BREAST CANCER: Zambetti M, et al. Ann Oncol 1996;7(5):481-5.
Reference Information (3)
BREAST CANCER: Gion M, et al. Eur J Cancer 1991;27(8):996-1002.
Reference Information (4)
BREAST CANCER: Tannock I, et al. J Clin Oncol 1988;6(9):1377-87.
Treatment Plan Summary
DISEASE: Breast (Advanced/Adjuvant); THERAPY: methotrexate 40 mg/m2 IV Day 1, fluorouracil 600 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days. COURSE: 8 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/1/2016 3:41:37 PM Page 1 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
methotrexate PF (TREXALL) injection 40 mg/m2 (Treatment Plan)
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
fluorouracil (ADRUCIL) injection 600 mg/m2 (Treatment Plan)
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5-15 Minutes
600 mg/m2 IV push.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
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,
AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: fluorouracil, methotrexate and cyclophosphamide for 120 minutes.
Cycle 2 – 11/22/2016 through 12/12/2016 (21 days), Planned
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/1/2016 3:41:37 PM Page 2 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 2 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced/Adjuvant); THERAPY: methotrexate 40 mg/m2 IV Day 1, fluorouracil 600 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days. COURSE: 8 cycles or 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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/1/2016 3:41:37 PM Page 3 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
methotrexate PF (TREXALL) injection 40 mg/m2 (Treatment Plan)
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
fluorouracil (ADRUCIL) injection 600 mg/m2 (Treatment Plan)
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5-15 Minutes
600 mg/m2 IV push.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
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,
AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: fluorouracil, methotrexate and cyclophosphamide for 120 minutes.
Cycle 3 – 12/13/2016 through 1/2/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced/Adjuvant); THERAPY: methotrexate 40 mg/m2 IV Day 1, fluorouracil 600 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days. COURSE: 8 cycles or 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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/1/2016 3:41:37 PM Page 4 of 12
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 or equal to 100K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
methotrexate PF (TREXALL) injection 40 mg/m2 (Treatment Plan)
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
fluorouracil (ADRUCIL) injection 600 mg/m2 (Treatment Plan)
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5-15 Minutes
600 mg/m2 IV push.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
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,
AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: fluorouracil, methotrexate and cyclophosphamide for 120 minutes.
Cycle 4 – 1/3/2017 through 1/23/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced/Adjuvant); THERAPY: methotrexate 40 mg/m2 IV Day 1, fluorouracil 600 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days. COURSE: 8 cycles or until disease progression.
Consent
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/1/2016 3:41:37 PM Page 5 of 12
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.
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+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
methotrexate PF (TREXALL) injection 40 mg/m2 (Treatment Plan)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/1/2016 3:41:37 PM Page 6 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
fluorouracil (ADRUCIL) injection 600 mg/m2 (Treatment Plan)
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5-15 Minutes
600 mg/m2 IV push.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
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,
AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: fluorouracil, methotrexate and cyclophosphamide for 120 minutes.
Cycle 5 – 1/24/2017 through 2/13/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced/Adjuvant); THERAPY: methotrexate 40 mg/m2 IV Day 1, fluorouracil 600 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days. COURSE: 8 cycles or 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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/1/2016 3:41:37 PM Page 7 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
methotrexate PF (TREXALL) injection 40 mg/m2 (Treatment Plan)
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
fluorouracil (ADRUCIL) injection 600 mg/m2 (Treatment Plan)
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5-15 Minutes
600 mg/m2 IV push.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
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,
AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: fluorouracil, methotrexate and cyclophosphamide for 120 minutes.
Cycle 6 – 2/14/2017 through 3/6/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced/Adjuvant); THERAPY: methotrexate 40 mg/m2 IV Day 1, fluorouracil 600 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days. COURSE: 8 cycles or 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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/1/2016 3:41:37 PM Page 8 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
methotrexate PF (TREXALL) injection 40 mg/m2 (Treatment Plan)
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
fluorouracil (ADRUCIL) injection 600 mg/m2 (Treatment Plan)
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5-15 Minutes
600 mg/m2 IV push.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/1/2016 3:41:37 PM Page 9 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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,
AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: fluorouracil, methotrexate and cyclophosphamide for 120 minutes.
Cycle 7 – 3/7/2017 through 3/27/2017 (21 days), Planned
Day 1, Cycle 7 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced/Adjuvant); THERAPY: methotrexate 40 mg/m2 IV Day 1, fluorouracil 600 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days. COURSE: 8 cycles or 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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/1/2016 3:41:37 PM Page 10 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
methotrexate PF (TREXALL) injection 40 mg/m2 (Treatment Plan)
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
fluorouracil (ADRUCIL) injection 600 mg/m2 (Treatment Plan)
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5-15 Minutes
600 mg/m2 IV push.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
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,
AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: fluorouracil, methotrexate and cyclophosphamide for 120 minutes.
Cycle 8 – 3/28/2017 through 4/17/2017 (21 days), Planned
Day 1, Cycle 8 – Planned for 3/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced/Adjuvant); THERAPY: methotrexate 40 mg/m2 IV Day 1, fluorouracil 600 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days. COURSE: 8 cycles or 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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/1/2016 3:41:37 PM Page 11 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
methotrexate PF (TREXALL) injection 40 mg/m2 (Treatment Plan)
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
fluorouracil (ADRUCIL) injection 600 mg/m2 (Treatment Plan)
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5-15 Minutes
600 mg/m2 IV push.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Care Planning for: {UWONC SURVIVORSHIP PLANNING:7700070}
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
ZZtestonc,Andrew [2428787]
11/1/2016 3:41:37 PM Page 12 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org