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

/clinical/cckm-tools/content/beacon-protocols/gi/name-114155-en.cckm

201708223

page

100

UWHC,UWMF,

Tools,

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

CSC GI Bevacizumab(28D:1,15) Fluorouacil(28D:1,15) Irinotecan(28D:1,15) Leucovorin(28D:1,15) Oxaliplatin (28D:1,15) VER: 8-15-17 (HL 6099)

CSC GI Bevacizumab(28D:1,15) Fluorouacil(28D:1,15) Irinotecan(28D:1,15) Leucovorin(28D:1,15) Oxaliplatin (28D:1,15) VER: 8-15-17 (HL 6099) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI BEVACIZUMAB(28D:1,15)/FLUOROURACIL(28D:1,15)/IRINOTECAN(28D:1,15)/LEUCOVORIN
(28D:1,15)/OXALIPLATIN(28D:1,15) VER: 8-15-17 –  Properties
Pre-Cycle –  8/2/2017 through 8/8/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Normal, 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
URINALYSIS, NO MICROSCOPY
Expected: S Approximate, Expires: S+365, Normal, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S Approximate, Expires: S+365, Routine
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 1 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy., 8 mg, Disp-36 tab, R-1, 1 X DAILY
starting S
loperamide (IMODIUM) 2 MG tab
Take 2 tab orally 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-1 each, R-0, starting S, No Print
Use for irinotecan-induced late-onset diarrhea. Available over the counter
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Take Day 4 thru 8 and Day 18 thru 22., 300 mcg, Disp-10 Syringe,
R-6, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Take on Day 4 thru 8 and Day 18 thru 22., 480 mcg, Disp-10
Syringe, R-6, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 –  8/9/2017 through 9/5/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/9/2017
Treatment Plan Information
Reference Information (1)
COLON AND RECTAL CANCER: Loupakis F, et al.  N Engl J Med 2014;371:1609-18.
Reference Information (2)
COLON AND RECTAL CANCER: Cremolini C, et al.  Lancet Oncol 2015;16:1306-15.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 2 of 44
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: ANC, Platelets, Creatinine, Total Bilirubin, and Urine Protein.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
75K/µL or Creatinine greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 30 mL/min or Total Bilirubin
greater than 1.5 X ULN or Urine Protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to
160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Irinotecan: Monitor patient during infusion for cholinergic syndrome (rhinitis, hypersalivation, lacrimation, diaphoresis,
abdominal cramping) and early-onset diarrhea.
Patient Instructions(1)
Oxaliplatin: Educate patient about neuropathy exacerbated by cold.
Patient Instructions(2)
Irinotecan: Educate patient about late-onset diarrhea.
Patient Instructions(3)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 3 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
bevacizumab (AVASTIN) 400 mg in sodium chloride 0.9 % 100 mL bag
400 mg (rounded from 405 mg = 5 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk.  See Emergency Medications. Administer over 10 minutes. Incompatible with Dextrose.
irinotecan CONVENTIONAL (CAMPTOSAR) 323.4 mg in dextrose 5 % 250 mL bag
323.4 mg (165 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 minutes. Administer prior to oxaliplatin.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Incompatible with Sodium Chloride. Allow adequate flushing with
Dextrose 5% in Water when necessary between chemotherapy treatment 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 (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) home infusion bag 6,272 mg
6,272 mg (3,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil dose = 3200 mg/m2 administered as a single continuous infusion IV over 48 hours (total dose = 3200
mg/m2 IV over 48 hours 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, cholinergic toxicity, Administer over 1
Minutes
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC without DIFF, ANC (or CBC with DIFF if done locally), Creatinine, Total Bilirubin, Electolytes, Glucose, BUN;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, irinotecan, oxaliplatin, leucovorin, and fluorouracil for 240
minutes
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 4 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 without DIFF, ANC (or CBC with DIFF
if done locally), Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Electrolytes, Glucose, BUN, Urinalysis (without
microscopy), CEA; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, irinotecan, oxaliplatin, leucovorin, and
fluorouracil for 240 minutes
Day 3 (Pump Disconnect), Cycle 1 –  Planned for 8/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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 48-hour fluorouracil infusion.
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 8/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 5 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, and Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
75K/µL or Creatinine greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 30 mL/min or Total Bilirubin
greater than 1.5 X ULN or Blood Pressure greater than or equal to 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Irinotecan: Monitor patient during infusion for cholinergic syndrome (rhinitis, hypersalivation, lacrimation, diaphoresis,
abdominal cramping) and early-onset diarrhea.
Patient Instructions(1)
Oxaliplatin: Educate patient about neuropathy exacerbated by cold.
Patient Instructions(2)
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 6 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Irinotecan: Educate patient about late-onset diarrhea.
Patient Instructions(3)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
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
bevacizumab (AVASTIN) 400 mg in sodium chloride 0.9 % 100 mL bag
400 mg (rounded from 405 mg = 5 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk.  See Emergency Medications. Administer over 10 minutes. Incompatible with Dextrose.
irinotecan CONVENTIONAL (CAMPTOSAR) 323.4 mg in dextrose 5 % 250 mL bag
323.4 mg (165 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 minutes. Administer prior to oxaliplatin.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 7 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Incompatible with Sodium Chloride. Allow adequate
flushing with Dextrose 5% in Water when necessary between chemotherapy treatment 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 (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) home infusion bag 6,272 mg
6,272 mg (3,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil dose = 3200 mg/m2 administered as a single continuous infusion IV over 48 hours (total dose = 3200
mg/m2 IV over 48 hours 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, cholinergic toxicity, Administer over 1
Minutes
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 8/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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 48-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]
8/9/2017 2:54:55 PM Page 8 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Cycle 2 –  9/6/2017 through 10/3/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 9 of 44
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: ANC, Platelets, Creatinine, Total Bilirubin, and Urine Protein.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
75K/µL or Creatinine greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 30 mL/min or Total Bilirubin
greater than 1.5 X ULN or Urine Protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to
160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Irinotecan: Monitor patient during infusion for cholinergic syndrome (rhinitis, hypersalivation, lacrimation, diaphoresis,
abdominal cramping) and early-onset diarrhea.
Patient Instructions(1)
Oxaliplatin: Educate patient about neuropathy exacerbated by cold.
Patient Instructions(2)
Irinotecan: Educate patient about late-onset diarrhea.
Patient Instructions(3)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 10 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
bevacizumab (AVASTIN) 400 mg in sodium chloride 0.9 % 100 mL bag
400 mg (rounded from 405 mg = 5 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk.  See Emergency Medications. Administer over 10 minutes. Incompatible with Dextrose.
irinotecan CONVENTIONAL (CAMPTOSAR) 323.4 mg in dextrose 5 % 250 mL bag
323.4 mg (165 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 minutes. Administer prior to oxaliplatin.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Incompatible with Sodium Chloride. Allow adequate flushing with
Dextrose 5% in Water when necessary between chemotherapy treatment 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 (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) home infusion bag 6,272 mg
6,272 mg (3,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil dose = 3200 mg/m2 administered as a single continuous infusion IV over 48 hours (total dose = 3200
mg/m2 IV over 48 hours 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, cholinergic toxicity, Administer over 1
Minutes
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC without DIFF, ANC (or CBC with DIFF if done locally), Creatinine, Total Bilirubin, Electolytes, Glucose, BUN;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, irinotecan, oxaliplatin, leucovorin, and fluorouracil for 240
minutes
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 11 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 without DIFF, ANC (or CBC with DIFF
if done locally), Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Electrolytes, Glucose, BUN, Urinalysis (without
microscopy), CEA; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, irinotecan, oxaliplatin, leucovorin, and
fluorouracil for 240 minutes
Day 3 (Pump Disconnect), Cycle 2 –  Planned for 9/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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 48-hour fluorouracil infusion.
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 9/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 12 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, and Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
75K/µL or Creatinine greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 30 mL/min or Total Bilirubin
greater than 1.5 X ULN or Blood Pressure greater than or equal to 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Irinotecan: Monitor patient during infusion for cholinergic syndrome (rhinitis, hypersalivation, lacrimation, diaphoresis,
abdominal cramping) and early-onset diarrhea.
Patient Instructions(1)
Oxaliplatin: Educate patient about neuropathy exacerbated by cold.
Patient Instructions(2)
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 13 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Irinotecan: Educate patient about late-onset diarrhea.
Patient Instructions(3)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
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
bevacizumab (AVASTIN) 400 mg in sodium chloride 0.9 % 100 mL bag
400 mg (rounded from 405 mg = 5 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk.  See Emergency Medications. Administer over 10 minutes. Incompatible with Dextrose.
irinotecan CONVENTIONAL (CAMPTOSAR) 323.4 mg in dextrose 5 % 250 mL bag
323.4 mg (165 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 minutes. Administer prior to oxaliplatin.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 14 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Incompatible with Sodium Chloride. Allow adequate
flushing with Dextrose 5% in Water when necessary between chemotherapy treatment 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 (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) home infusion bag 6,272 mg
6,272 mg (3,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil dose = 3200 mg/m2 administered as a single continuous infusion IV over 48 hours (total dose = 3200
mg/m2 IV over 48 hours 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, cholinergic toxicity, Administer over 1
Minutes
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 9/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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 48-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]
8/9/2017 2:54:55 PM Page 15 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Cycle 3 –  10/4/2017 through 10/31/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 10/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 16 of 44
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: ANC, Platelets, Creatinine, Total Bilirubin, and Urine Protein.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
75K/µL or Creatinine greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 30 mL/min or Total Bilirubin
greater than 1.5 X ULN or Urine Protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to
160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Irinotecan: Monitor patient during infusion for cholinergic syndrome (rhinitis, hypersalivation, lacrimation, diaphoresis,
abdominal cramping) and early-onset diarrhea.
Patient Instructions(1)
Oxaliplatin: Educate patient about neuropathy exacerbated by cold.
Patient Instructions(2)
Irinotecan: Educate patient about late-onset diarrhea.
Patient Instructions(3)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 17 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
bevacizumab (AVASTIN) 400 mg in sodium chloride 0.9 % 100 mL bag
400 mg (rounded from 405 mg = 5 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk.  See Emergency Medications. Administer over 10 minutes. Incompatible with Dextrose.
irinotecan CONVENTIONAL (CAMPTOSAR) 323.4 mg in dextrose 5 % 250 mL bag
323.4 mg (165 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 minutes. Administer prior to oxaliplatin.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Incompatible with Sodium Chloride. Allow adequate flushing with
Dextrose 5% in Water when necessary between chemotherapy treatment 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 (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) home infusion bag 6,272 mg
6,272 mg (3,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil dose = 3200 mg/m2 administered as a single continuous infusion IV over 48 hours (total dose = 3200
mg/m2 IV over 48 hours 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, cholinergic toxicity, Administer over 1
Minutes
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC without DIFF, ANC (or CBC with DIFF if done locally), Creatinine, Total Bilirubin, Electolytes, Glucose, BUN;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, irinotecan, oxaliplatin, leucovorin, and fluorouracil for 240
minutes
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 18 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 without DIFF, ANC (or CBC with DIFF
if done locally), Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Electrolytes, Glucose, BUN, Urinalysis (without
microscopy), CEA; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, irinotecan, oxaliplatin, leucovorin, and
fluorouracil for 240 minutes
Day 3 (Pump Disconnect), Cycle 3 –  Planned for 10/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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 48-hour fluorouracil infusion.
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 10/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 19 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, and Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
75K/µL or Creatinine greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 30 mL/min or Total Bilirubin
greater than 1.5 X ULN or Blood Pressure greater than or equal to 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Irinotecan: Monitor patient during infusion for cholinergic syndrome (rhinitis, hypersalivation, lacrimation, diaphoresis,
abdominal cramping) and early-onset diarrhea.
Patient Instructions(1)
Oxaliplatin: Educate patient about neuropathy exacerbated by cold.
Patient Instructions(2)
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 20 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Irinotecan: Educate patient about late-onset diarrhea.
Patient Instructions(3)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
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
bevacizumab (AVASTIN) 400 mg in sodium chloride 0.9 % 100 mL bag
400 mg (rounded from 405 mg = 5 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk.  See Emergency Medications. Administer over 10 minutes. Incompatible with Dextrose.
irinotecan CONVENTIONAL (CAMPTOSAR) 323.4 mg in dextrose 5 % 250 mL bag
323.4 mg (165 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 minutes. Administer prior to oxaliplatin.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 21 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Incompatible with Sodium Chloride. Allow adequate
flushing with Dextrose 5% in Water when necessary between chemotherapy treatment 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 (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) home infusion bag 6,272 mg
6,272 mg (3,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil dose = 3200 mg/m2 administered as a single continuous infusion IV over 48 hours (total dose = 3200
mg/m2 IV over 48 hours 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, cholinergic toxicity, Administer over 1
Minutes
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 10/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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 48-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]
8/9/2017 2:54:55 PM Page 22 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Cycle 4 –  11/1/2017 through 11/28/2017 (28 days), Planned
Day 1, Cycle 4 –  Planned for 11/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 23 of 44
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: ANC, Platelets, Creatinine, Total Bilirubin, and Urine Protein.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
75K/µL or Creatinine greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 30 mL/min or Total Bilirubin
greater than 1.5 X ULN or Urine Protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to
160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Irinotecan: Monitor patient during infusion for cholinergic syndrome (rhinitis, hypersalivation, lacrimation, diaphoresis,
abdominal cramping) and early-onset diarrhea.
Patient Instructions(1)
Oxaliplatin: Educate patient about neuropathy exacerbated by cold.
Patient Instructions(2)
Irinotecan: Educate patient about late-onset diarrhea.
Patient Instructions(3)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 24 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
bevacizumab (AVASTIN) 400 mg in sodium chloride 0.9 % 100 mL bag
400 mg (rounded from 405 mg = 5 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk.  See Emergency Medications. Administer over 10 minutes. Incompatible with Dextrose.
irinotecan CONVENTIONAL (CAMPTOSAR) 323.4 mg in dextrose 5 % 250 mL bag
323.4 mg (165 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 minutes. Administer prior to oxaliplatin.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Incompatible with Sodium Chloride. Allow adequate flushing with
Dextrose 5% in Water when necessary between chemotherapy treatment 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 (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) home infusion bag 6,272 mg
6,272 mg (3,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil dose = 3200 mg/m2 administered as a single continuous infusion IV over 48 hours (total dose = 3200
mg/m2 IV over 48 hours 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, cholinergic toxicity, Administer over 1
Minutes
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC without DIFF, ANC (or CBC with DIFF if done locally), Creatinine, Total Bilirubin, Electolytes, Glucose, BUN;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, irinotecan, oxaliplatin, leucovorin, and fluorouracil for 240
minutes
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 25 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 without DIFF, ANC (or CBC with DIFF
if done locally), Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Electrolytes, Glucose, BUN, Urinalysis (without
microscopy), CEA; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, irinotecan, oxaliplatin, leucovorin, and
fluorouracil for 240 minutes
Day 3 (Pump Disconnect), Cycle 4 –  Planned for 11/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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 48-hour fluorouracil infusion.
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 11/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 26 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, and Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
75K/µL or Creatinine greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 30 mL/min or Total Bilirubin
greater than 1.5 X ULN or Blood Pressure greater than or equal to 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Irinotecan: Monitor patient during infusion for cholinergic syndrome (rhinitis, hypersalivation, lacrimation, diaphoresis,
abdominal cramping) and early-onset diarrhea.
Patient Instructions(1)
Oxaliplatin: Educate patient about neuropathy exacerbated by cold.
Patient Instructions(2)
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 27 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Irinotecan: Educate patient about late-onset diarrhea.
Patient Instructions(3)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
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
bevacizumab (AVASTIN) 400 mg in sodium chloride 0.9 % 100 mL bag
400 mg (rounded from 405 mg = 5 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk.  See Emergency Medications. Administer over 10 minutes. Incompatible with Dextrose.
irinotecan CONVENTIONAL (CAMPTOSAR) 323.4 mg in dextrose 5 % 250 mL bag
323.4 mg (165 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 minutes. Administer prior to oxaliplatin.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 28 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Incompatible with Sodium Chloride. Allow adequate
flushing with Dextrose 5% in Water when necessary between chemotherapy treatment 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 (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) home infusion bag 6,272 mg
6,272 mg (3,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil dose = 3200 mg/m2 administered as a single continuous infusion IV over 48 hours (total dose = 3200
mg/m2 IV over 48 hours 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, cholinergic toxicity, Administer over 1
Minutes
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 11/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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 48-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]
8/9/2017 2:54:55 PM Page 29 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Cycle 5 –  11/29/2017 through 12/26/2017 (28 days), Planned
Day 1, Cycle 5 –  Planned for 11/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 30 of 44
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: ANC, Platelets, Creatinine, Total Bilirubin, and Urine Protein.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
75K/µL or Creatinine greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 30 mL/min or Total Bilirubin
greater than 1.5 X ULN or Urine Protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to
160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Irinotecan: Monitor patient during infusion for cholinergic syndrome (rhinitis, hypersalivation, lacrimation, diaphoresis,
abdominal cramping) and early-onset diarrhea.
Patient Instructions(1)
Oxaliplatin: Educate patient about neuropathy exacerbated by cold.
Patient Instructions(2)
Irinotecan: Educate patient about late-onset diarrhea.
Patient Instructions(3)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 31 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
bevacizumab (AVASTIN) 400 mg in sodium chloride 0.9 % 100 mL bag
400 mg (rounded from 405 mg = 5 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk.  See Emergency Medications. Administer over 10 minutes. Incompatible with Dextrose.
irinotecan CONVENTIONAL (CAMPTOSAR) 323.4 mg in dextrose 5 % 250 mL bag
323.4 mg (165 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 minutes. Administer prior to oxaliplatin.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Incompatible with Sodium Chloride. Allow adequate flushing with
Dextrose 5% in Water when necessary between chemotherapy treatment 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 (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) home infusion bag 6,272 mg
6,272 mg (3,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil dose = 3200 mg/m2 administered as a single continuous infusion IV over 48 hours (total dose = 3200
mg/m2 IV over 48 hours 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, cholinergic toxicity, Administer over 1
Minutes
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC without DIFF, ANC (or CBC with DIFF if done locally), Creatinine, Total Bilirubin, Electolytes, Glucose, BUN;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, irinotecan, oxaliplatin, leucovorin, and fluorouracil for 240
minutes
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 32 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 without DIFF, ANC (or CBC with DIFF
if done locally), Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Electrolytes, Glucose, BUN, Urinalysis (without
microscopy), CEA; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, irinotecan, oxaliplatin, leucovorin, and
fluorouracil for 240 minutes
Day 3 (Pump Disconnect), Cycle 5 –  Planned for 12/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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 48-hour fluorouracil infusion.
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 12/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 33 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, and Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
75K/µL or Creatinine greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 30 mL/min or Total Bilirubin
greater than 1.5 X ULN or Blood Pressure greater than or equal to 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Irinotecan: Monitor patient during infusion for cholinergic syndrome (rhinitis, hypersalivation, lacrimation, diaphoresis,
abdominal cramping) and early-onset diarrhea.
Patient Instructions(1)
Oxaliplatin: Educate patient about neuropathy exacerbated by cold.
Patient Instructions(2)
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 34 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Irinotecan: Educate patient about late-onset diarrhea.
Patient Instructions(3)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
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
bevacizumab (AVASTIN) 400 mg in sodium chloride 0.9 % 100 mL bag
400 mg (rounded from 405 mg = 5 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk.  See Emergency Medications. Administer over 10 minutes. Incompatible with Dextrose.
irinotecan CONVENTIONAL (CAMPTOSAR) 323.4 mg in dextrose 5 % 250 mL bag
323.4 mg (165 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 minutes. Administer prior to oxaliplatin.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 35 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Incompatible with Sodium Chloride. Allow adequate
flushing with Dextrose 5% in Water when necessary between chemotherapy treatment 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 (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) home infusion bag 6,272 mg
6,272 mg (3,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil dose = 3200 mg/m2 administered as a single continuous infusion IV over 48 hours (total dose = 3200
mg/m2 IV over 48 hours 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, cholinergic toxicity, Administer over 1
Minutes
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 12/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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 48-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]
8/9/2017 2:54:55 PM Page 36 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Cycle 6 –  12/27/2017 through 1/23/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 12/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 37 of 44
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: ANC, Platelets, Creatinine, Total Bilirubin, and Urine Protein.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
75K/µL or Creatinine greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 30 mL/min or Total Bilirubin
greater than 1.5 X ULN or Urine Protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to
160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Irinotecan: Monitor patient during infusion for cholinergic syndrome (rhinitis, hypersalivation, lacrimation, diaphoresis,
abdominal cramping) and early-onset diarrhea.
Patient Instructions(1)
Oxaliplatin: Educate patient about neuropathy exacerbated by cold.
Patient Instructions(2)
Irinotecan: Educate patient about late-onset diarrhea.
Patient Instructions(3)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 38 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
bevacizumab (AVASTIN) 400 mg in sodium chloride 0.9 % 100 mL bag
400 mg (rounded from 405 mg = 5 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk.  See Emergency Medications. Administer over 10 minutes. Incompatible with Dextrose.
irinotecan CONVENTIONAL (CAMPTOSAR) 323.4 mg in dextrose 5 % 250 mL bag
323.4 mg (165 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 minutes. Administer prior to oxaliplatin.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Incompatible with Sodium Chloride. Allow adequate flushing with
Dextrose 5% in Water when necessary between chemotherapy treatment 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 (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) home infusion bag 6,272 mg
6,272 mg (3,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil dose = 3200 mg/m2 administered as a single continuous infusion IV over 48 hours (total dose = 3200
mg/m2 IV over 48 hours 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, cholinergic toxicity, Administer over 1
Minutes
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC without DIFF, ANC (or CBC with DIFF if done locally), Creatinine, Total Bilirubin, Electolytes, Glucose, BUN;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, irinotecan, oxaliplatin, leucovorin, and fluorouracil for 240
minutes
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 39 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 without DIFF, ANC (or CBC with DIFF
if done locally), Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Electrolytes, Glucose, BUN, Urinalysis (without
microscopy), CEA; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, irinotecan, oxaliplatin, leucovorin, and
fluorouracil for 240 minutes
Day 3 (Pump Disconnect), Cycle 6 –  Planned for 12/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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 48-hour fluorouracil infusion.
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 1/10/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 40 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, and Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
75K/µL or Creatinine greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 30 mL/min or Total Bilirubin
greater than 1.5 X ULN or Blood Pressure greater than or equal to 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Irinotecan: Monitor patient during infusion for cholinergic syndrome (rhinitis, hypersalivation, lacrimation, diaphoresis,
abdominal cramping) and early-onset diarrhea.
Patient Instructions(1)
Oxaliplatin: Educate patient about neuropathy exacerbated by cold.
Patient Instructions(2)
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 41 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Irinotecan: Educate patient about late-onset diarrhea.
Patient Instructions(3)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
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
bevacizumab (AVASTIN) 400 mg in sodium chloride 0.9 % 100 mL bag
400 mg (rounded from 405 mg = 5 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity Risk.  See Emergency Medications. Administer over 10 minutes. Incompatible with Dextrose.
irinotecan CONVENTIONAL (CAMPTOSAR) 323.4 mg in dextrose 5 % 250 mL bag
323.4 mg (165 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 minutes. Administer prior to oxaliplatin.
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Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 42 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Incompatible with Sodium Chloride. Allow adequate
flushing with Dextrose 5% in Water when necessary between chemotherapy treatment 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 (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) home infusion bag 6,272 mg
6,272 mg (3,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil dose = 3200 mg/m2 administered as a single continuous infusion IV over 48 hours (total dose = 3200
mg/m2 IV over 48 hours 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, cholinergic toxicity, Administer over 1
Minutes
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 1/12/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 165 mg/m2
IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 3200
mg/m2 administered as a continuous infusion IV over 48 hours Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6
cycles.
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 48-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]
8/9/2017 2:54:55 PM Page 43 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Zztestonc,Jeff J [2507481]
8/9/2017 2:54:55 PM Page 44 of 44
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org