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CSC GI Fluorouracil(28D:1,15) Leucovorin(28D:1,15) Liposomal Irinotecan(28D:1,15) VER 8-15-17 (HL 6108)

CSC GI Fluorouracil(28D:1,15) Leucovorin(28D:1,15) Liposomal Irinotecan(28D:1,15) VER 8-15-17 (HL 6108) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI FLUOROURACIL(28D:1,15)/LEUCOVORIN(28D:1,15)/LIPOSOMAL IRINOTECAN(28D:1,15) VER: 8-15-
17 –  Properties
Pre-Cycle –  8/3/2017 through 8/9/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 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
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
BUN
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
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S Approximate, Expires: S+365, Routine
UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan LIPOSOMAL therapy.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 1 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-24 tab, R-5, 1 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
loperamide 2 MG cap
Take 2 tab by mouth with 1st loose stool followed by 1 tab every 2h or 2 tab every 4h until no diarrhea x12h. Max
dose=8 tab/day, Disp-30 cap, R-5, starting S, Local Printer
Counsel patient to purchase over the counter if not covered by insurance and provide instructions for use.
Cycle 1 –  8/10/2017 through 9/6/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/10/2017
Treatment Plan Information
Reference Information (1)
PANCREATIC CANCER: Wang-Gillam A, et al.  Lancet 2016;387:545-57.
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; 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, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to irinotecan LIPOSOMAL can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care.  See Emergency Medications.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 2 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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 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
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
irinotecan LIPOSOMAL (ONIVYDE) 137.213 mg in dextrose 5 % 500 mL bag
137.213 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer IV over 90 minutes PRIOR to leucovorin and fluorouracil. Hypersensitivity reaction to irinotecan LIPOSOMAL
can occur.  For first and second dose, patient should be treated in a location to optimize emergency care.  See
Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer IV over 30 minutes AFTER irinotecan LIPOSOMAL.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 3 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan LIPOSOMAL,
leucovorin, fluorouracil for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, CEA; CHEMOTHERAPY ROOM
APPOINTMENT: irinotecan LIPOSOMAL, leucovorin, fluorouracil for 180 minutes.
Day 3 (Pump Disconnect), Cycle 1 –  Planned for 8/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 1 –  Planned for 8/17/2017
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 4 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 –  Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; 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 WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 5 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to irinotecan LIPOSOMAL can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care.  See Emergency Medications.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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.
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 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
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 6 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

irinotecan LIPOSOMAL (ONIVYDE) 137.213 mg in dextrose 5 % 500 mL bag
137.213 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer IV over 90 minutes PRIOR to leucovorin and fluorouracil. Hypersensitivity reaction to irinotecan LIPOSOMAL
can occur.  For first and second dose, patient should be treated in a location to optimize emergency care.  See
Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer IV over 30 minutes AFTER irinotecan LIPOSOMAL.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 1 –  Planned for 8/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 7 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  9/7/2017 through 10/4/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; 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 WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
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
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 8 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to irinotecan LIPOSOMAL can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care.  See Emergency Medications.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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.
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 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
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 9 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
irinotecan LIPOSOMAL (ONIVYDE) 137.213 mg in dextrose 5 % 500 mL bag
137.213 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer IV over 90 minutes PRIOR to leucovorin and fluorouracil. Hypersensitivity reaction to irinotecan LIPOSOMAL
can occur.  For first and second dose, patient should be treated in a location to optimize emergency care.  See
Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer IV over 30 minutes AFTER irinotecan LIPOSOMAL.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan LIPOSOMAL,
leucovorin, fluorouracil for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, CEA; CHEMOTHERAPY ROOM
APPOINTMENT: irinotecan LIPOSOMAL, leucovorin, fluorouracil for 180 minutes.
Day 3 (Pump Disconnect), Cycle 2 –  Planned for 9/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 10 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 2 –  Planned for 9/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 –  Planned for 9/21/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 11 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; 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 WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 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 1,500/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to irinotecan LIPOSOMAL can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care.  See Emergency Medications.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 12 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
irinotecan LIPOSOMAL (ONIVYDE) 137.213 mg in dextrose 5 % 500 mL bag
137.213 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer IV over 90 minutes PRIOR to leucovorin and fluorouracil. Hypersensitivity reaction to irinotecan LIPOSOMAL
can occur.  For first and second dose, patient should be treated in a location to optimize emergency care.  See
Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer IV over 30 minutes AFTER irinotecan LIPOSOMAL.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 2 –  Planned for 9/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 13 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  10/5/2017 through 11/1/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; 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 WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 14 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Routine
BUN
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
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 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 1,500/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to irinotecan LIPOSOMAL can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care.  See Emergency Medications.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 15 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
irinotecan LIPOSOMAL (ONIVYDE) 137.213 mg in dextrose 5 % 500 mL bag
137.213 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer IV over 90 minutes PRIOR to leucovorin and fluorouracil. Hypersensitivity reaction to irinotecan LIPOSOMAL
can occur.  For first and second dose, patient should be treated in a location to optimize emergency care.  See
Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer IV over 30 minutes AFTER irinotecan LIPOSOMAL.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan LIPOSOMAL,
leucovorin, fluorouracil for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 16 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, CEA; CHEMOTHERAPY ROOM
APPOINTMENT: irinotecan LIPOSOMAL, leucovorin, fluorouracil for 180 minutes.
Day 3 (Pump Disconnect), Cycle 3 –  Planned for 10/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 3 –  Planned for 10/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 17 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 –  Planned for 10/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; 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 WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 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 1,500/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to irinotecan LIPOSOMAL can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care.  See Emergency Medications.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Flush Venous Access Device per Guidelines
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 18 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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 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.
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 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
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
irinotecan LIPOSOMAL (ONIVYDE) 137.213 mg in dextrose 5 % 500 mL bag
137.213 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer IV over 90 minutes PRIOR to leucovorin and fluorouracil. Hypersensitivity reaction to irinotecan LIPOSOMAL
can occur.  For first and second dose, patient should be treated in a location to optimize emergency care.  See
Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer IV over 30 minutes AFTER irinotecan LIPOSOMAL.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 19 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic
syndrome, Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 3 –  Planned for 10/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  11/2/2017 through 11/29/2017 (28 days), Planned
Day 1, Cycle 4 –  Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 20 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
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
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 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 1,500/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to irinotecan LIPOSOMAL can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care.  See Emergency Medications.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 21 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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 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
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
irinotecan LIPOSOMAL (ONIVYDE) 137.213 mg in dextrose 5 % 500 mL bag
137.213 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer IV over 90 minutes PRIOR to leucovorin and fluorouracil. Hypersensitivity reaction to irinotecan LIPOSOMAL
can occur.  For first and second dose, patient should be treated in a location to optimize emergency care.  See
Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer IV over 30 minutes AFTER irinotecan LIPOSOMAL.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 22 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan LIPOSOMAL,
leucovorin, fluorouracil for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, CEA; CHEMOTHERAPY ROOM
APPOINTMENT: irinotecan LIPOSOMAL, leucovorin, fluorouracil for 180 minutes.
Day 3 (Pump Disconnect), Cycle 4 –  Planned for 11/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 4 –  Planned for 11/9/2017
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 23 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 –  Planned for 11/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; 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 WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 24 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to irinotecan LIPOSOMAL can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care.  See Emergency Medications.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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.
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 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
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 25 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

irinotecan LIPOSOMAL (ONIVYDE) 137.213 mg in dextrose 5 % 500 mL bag
137.213 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer IV over 90 minutes PRIOR to leucovorin and fluorouracil. Hypersensitivity reaction to irinotecan LIPOSOMAL
can occur.  For first and second dose, patient should be treated in a location to optimize emergency care.  See
Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer IV over 30 minutes AFTER irinotecan LIPOSOMAL.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 4 –  Planned for 11/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 26 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  11/30/2017 through 12/27/2017 (28 days), Planned
Day 1, Cycle 5 –  Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; 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 WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
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
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 27 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to irinotecan LIPOSOMAL can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care.  See Emergency Medications.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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.
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 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
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 28 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
irinotecan LIPOSOMAL (ONIVYDE) 137.213 mg in dextrose 5 % 500 mL bag
137.213 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer IV over 90 minutes PRIOR to leucovorin and fluorouracil. Hypersensitivity reaction to irinotecan LIPOSOMAL
can occur.  For first and second dose, patient should be treated in a location to optimize emergency care.  See
Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer IV over 30 minutes AFTER irinotecan LIPOSOMAL.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan LIPOSOMAL,
leucovorin, fluorouracil for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, CEA; CHEMOTHERAPY ROOM
APPOINTMENT: irinotecan LIPOSOMAL, leucovorin, fluorouracil for 180 minutes.
Day 3 (Pump Disconnect), Cycle 5 –  Planned for 12/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 29 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 5 –  Planned for 12/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 –  Planned for 12/14/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 30 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; 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 WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 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 1,500/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to irinotecan LIPOSOMAL can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care.  See Emergency Medications.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 31 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
irinotecan LIPOSOMAL (ONIVYDE) 137.213 mg in dextrose 5 % 500 mL bag
137.213 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer IV over 90 minutes PRIOR to leucovorin and fluorouracil. Hypersensitivity reaction to irinotecan LIPOSOMAL
can occur.  For first and second dose, patient should be treated in a location to optimize emergency care.  See
Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer IV over 30 minutes AFTER irinotecan LIPOSOMAL.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 5 –  Planned for 12/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 32 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  12/28/2017 through 1/24/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; 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 WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 33 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Routine
BUN
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
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 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 1,500/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to irinotecan LIPOSOMAL can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care.  See Emergency Medications.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 34 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
irinotecan LIPOSOMAL (ONIVYDE) 137.213 mg in dextrose 5 % 500 mL bag
137.213 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer IV over 90 minutes PRIOR to leucovorin and fluorouracil. Hypersensitivity reaction to irinotecan LIPOSOMAL
can occur.  For first and second dose, patient should be treated in a location to optimize emergency care.  See
Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer IV over 30 minutes AFTER irinotecan LIPOSOMAL.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan LIPOSOMAL,
leucovorin, fluorouracil for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 35 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, CEA; CHEMOTHERAPY ROOM
APPOINTMENT: irinotecan LIPOSOMAL, leucovorin, fluorouracil for 180 minutes.
Day 3 (Pump Disconnect), Cycle 6 –  Planned for 12/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 6 –  Planned for 1/4/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 36 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 –  Planned for 1/11/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; 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 WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 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 1,500/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to irinotecan LIPOSOMAL can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care.  See Emergency Medications.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Flush Venous Access Device per Guidelines
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 37 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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 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.
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 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
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
irinotecan LIPOSOMAL (ONIVYDE) 137.213 mg in dextrose 5 % 500 mL bag
137.213 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer IV over 90 minutes PRIOR to leucovorin and fluorouracil. Hypersensitivity reaction to irinotecan LIPOSOMAL
can occur.  For first and second dose, patient should be treated in a location to optimize emergency care.  See
Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer IV over 30 minutes AFTER irinotecan LIPOSOMAL.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 38 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic
syndrome, Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 6 –  Planned for 1/13/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Adenocarcinoma (Advanced); THERAPY: irinotecan LIPOSOMAL 70 mg/m2 IV Day 1 and 15,
leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46
hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:52:34 AM Page 39 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org