/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-115954-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 Capecitabine(28D:1-21) Gemcitabine(28D:1,8,15) VER 8-15-17 (HL 5972)

CSC GI Capecitabine(28D:1-21) Gemcitabine(28D:1,8,15) VER 8-15-17 (HL 5972) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI CAPECITABINE(28D:1-21)/GEMCITABINE(28D:1,8,15) VER: 08-15-17 –  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: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
Cycle 1 –  8/9/2017 through 9/5/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/9/2017
Treatment Plan Information
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 1 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Reference Information (1)
PANCREATIC CANCER: Neoptolemos JP, et al. Lancet 2017;389(10073):1011-1024
Treatment Plan Summary
DISEASE: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.5 x ULN or AST greater than or equal to 2.5 x ULN or ALT greater than or equal to 2.5 x ULN or
Creatinine greater than or equal to 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 2 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site
irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take on Day 1 (PM) through Day 22 (AM)., 1,500 mg (rounded from 1,626.8 mg
= 830 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Round doses to available tablet sizes of 500 mg and 150 mg.
capecitabine (XELODA) 150 MG tab
Take 11 tabs by mouth 2 times daily. Take on Day 1 (PM) through Day 22 (AM)., 1,650 mg (rounded from 1,626.8 mg
= 830 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Round doses to available tablet sizes of 500 mg and 150 mg.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: gemcitabine for 60 minutes.
Day 8, Cycle 1 –  Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 3 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or
equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
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: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; CYCLE LENGTH: 28 days; COURSE: 6 cycles.
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 4 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 5 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  9/6/2017 through 10/3/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
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: CBC, ANC, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.5 x ULN or AST greater than or equal to 2.5 x ULN or ALT greater than or equal to 2.5 x ULN or
Creatinine greater than or equal to 1.5 mg/dL.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 6 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take on Day 1 (PM) through Day 22 (AM)., 1,500 mg (rounded from 1,626.8 mg
= 830 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Round doses to available tablet sizes of 500 mg and 150 mg.
capecitabine (XELODA) 150 MG tab
Take 11 tabs by mouth 2 times daily. Take on Day 1 (PM) through Day 22 (AM)., 1,650 mg (rounded from 1,626.8 mg
= 830 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Round doses to available tablet sizes of 500 mg and 150 mg.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 7 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be
done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
Day 8, Cycle 2 –  Planned for 9/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 8 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
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: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 9 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 10 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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: CBC, ANC, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.5 x ULN or AST greater than or equal to 2.5 x ULN or ALT greater than or equal to 2.5 x ULN or
Creatinine greater than or equal to 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 11 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take on Day 1 (PM) through Day 22 (AM)., 1,500 mg (rounded from 1,626.8 mg
= 830 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Round doses to available tablet sizes of 500 mg and 150 mg.
capecitabine (XELODA) 150 MG tab
Take 11 tabs by mouth 2 times daily. Take on Day 1 (PM) through Day 22 (AM)., 1,650 mg (rounded from 1,626.8 mg
= 830 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Round doses to available tablet sizes of 500 mg and 150 mg.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: gemcitabine for 60 minutes.
Day 8, Cycle 3 –  Planned for 10/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 12 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 13 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DISEASE: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 14 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 15 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.5 x ULN or AST greater than or equal to 2.5 x ULN or ALT greater than or equal to 2.5 x ULN or
Creatinine greater than or equal to 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take on Day 1 (PM) through Day 22 (AM)., 1,500 mg (rounded from 1,626.8 mg
= 830 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Round doses to available tablet sizes of 500 mg and 150 mg.
capecitabine (XELODA) 150 MG tab
Take 11 tabs by mouth 2 times daily. Take on Day 1 (PM) through Day 22 (AM)., 1,650 mg (rounded from 1,626.8 mg
= 830 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Round doses to available tablet sizes of 500 mg and 150 mg.
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 16 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for
60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: gemcitabine for 60 minutes.
Day 8, Cycle 4 –  Planned for 11/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 17 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
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: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 18 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 19 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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: CBC, ANC, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.5 x ULN or AST greater than or equal to 2.5 x ULN or ALT greater than or equal to 2.5 x ULN or
Creatinine greater than or equal to 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 20 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take on Day 1 (PM) through Day 22 (AM)., 1,500 mg (rounded from 1,626.8 mg
= 830 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Round doses to available tablet sizes of 500 mg and 150 mg.
capecitabine (XELODA) 150 MG tab
Take 11 tabs by mouth 2 times daily. Take on Day 1 (PM) through Day 22 (AM)., 1,650 mg (rounded from 1,626.8 mg
= 830 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Round doses to available tablet sizes of 500 mg and 150 mg.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: gemcitabine for 60 minutes.
Day 8, Cycle 5 –  Planned for 12/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 21 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 22 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Day 15, Cycle 5 –  Planned for 12/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 23 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 24 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.5 x ULN or AST greater than or equal to 2.5 x ULN or ALT greater than or equal to 2.5 x ULN or
Creatinine greater than or equal to 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 25 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Take 3 tabs by mouth 2 times daily. Take on Day 1 (PM) through Day 22 (AM)., 1,500 mg (rounded from 1,626.8 mg
= 830 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Round doses to available tablet sizes of 500 mg and 150 mg.
capecitabine (XELODA) 150 MG tab
Take 11 tabs by mouth 2 times daily. Take on Day 1 (PM) through Day 22 (AM)., 1,650 mg (rounded from 1,626.8 mg
= 830 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Round doses to available tablet sizes of 500 mg and 150 mg.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider.
Day 8, Cycle 6 –  Planned for 1/3/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 26 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
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: Pancreatic Cancer (Adjuvant); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15, capecitabine 830
mg/m2 by mouth twice daily Day 1 through 21; 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 27 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or
equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:25:21 PM Page 28 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org