/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-96627-en.cckm

201708223

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100

UWHC,UWMF,

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

CSC GI Bevacizumab Fluorouracil Irinotecan Leucovorin(28:D1,15) VER 8-15-17 (HL 423)

CSC GI Bevacizumab Fluorouracil Irinotecan Leucovorin(28:D1,15) VER 8-15-17 (HL 423) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI BEVACIZUMAB/FLUOROURACIL/IRINOTECAN/LEUCOVORIN(28D:1,15) VER: 8-15-17 –  Properties
Pre-Cycle –  8/1/2017 through 8/7/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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, 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
URINALYSIS, NO MICROSCOPY
Expected: S Approximate, Expires: S+365, Normal, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S Approximate, Expires: S+365, Routine
UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 1 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Page Or Call ___________
Notify Home infusion provider.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-24 tab, R-5, 1 X DAILY
starting S, Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
loperamide 2 MG cap
Take 2 tab by mouth with 1st loose stool followed by 1 tab every 2h or 2 tab every 4h until no diarrhea x12h. Max
dose=8 tab/day, Disp-30 cap, R-5, starting S, Local Printer
Counsel patient to purchase over the counter if not covered by insurance and provide instructions for use.
Cycle 1 –  8/8/2017 through 9/4/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/8/2017
Treatment Plan Information
Reference Information (1)
COLON AND RECTAL CANCER: Andre, et al. Eur J Cancer 1999;35:1343-7.
Reference Information (2)
COLON AND RECTAL CANCER: Tournigand, et al. J Clin Oncol 2004;23:229-37.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
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
or Urine protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 2 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea,
diaphoresis, or weakness).
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 3 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90
minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:
irinotecan/leucovorin/bevacizumab/fluorouracil for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN,  Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without microscopy,
CEA; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/leucovorin/bevacizumab /fluorouracil for 180 minutes.
Day 3 (Pump Disconnect), Cycle 1 –  Planned for 8/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 4 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 –  Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 5 of 38
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 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) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
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
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 6 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 1 –  Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  9/5/2017 through 10/2/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/5/2017
Treatment Plan Information
Reference Information (1)
COLON AND RECTAL CANCER: Andre, et al. Eur J Cancer 1999;35:1343-7.
Reference Information (2)
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 7 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

COLON AND RECTAL CANCER: Tournigand, et al. J Clin Oncol 2004;23:229-37.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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
UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
Treatment Conditions
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 8 of 38
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 and resulted: CBC, ANC, Urine Protein.
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
or Urine protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 9 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
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
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:
irinotecan/leucovorin/bevacizumab/fluorouracil for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN,  Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without microscopy,
CEA; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/leucovorin/bevacizumab /fluorouracil for 180 minutes.
Day 3 (Pump Disconnect), Cycle 2 –  Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 10 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 –  Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 11 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 12 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90
minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 2 –  Planned for 9/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 13 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  10/3/2017 through 10/30/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 10/3/2017
Treatment Plan Information
Reference Information (1)
COLON AND RECTAL CANCER: Andre, et al. Eur J Cancer 1999;35:1343-7.
Reference Information (2)
COLON AND RECTAL CANCER: Tournigand, et al. J Clin Oncol 2004;23:229-37.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 14 of 38
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
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
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
or Urine protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 15 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
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
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:
irinotecan/leucovorin/bevacizumab/fluorouracil for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN,  Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without microscopy,
CEA; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/leucovorin/bevacizumab /fluorouracil for 180 minutes.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 16 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Day 3 (Pump Disconnect), Cycle 3 –  Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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 46-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 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 17 of 38
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
or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 18 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
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
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 3 –  Planned for 10/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 19 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  10/31/2017 through 11/27/2017 (28 days), Planned
Day 1, Cycle 4 –  Planned for 10/31/2017
Treatment Plan Information
Reference Information (1)
COLON AND RECTAL CANCER: Andre, et al. Eur J Cancer 1999;35:1343-7.
Reference Information (2)
COLON AND RECTAL CANCER: Tournigand, et al. J Clin Oncol 2004;23:229-37.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 20 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
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
or Urine protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 21 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
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
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 22 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:
irinotecan/leucovorin/bevacizumab/fluorouracil for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN,  Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without microscopy,
CEA; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/leucovorin/bevacizumab /fluorouracil for 180 minutes.
Day 3 (Pump Disconnect), Cycle 4 –  Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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 46-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 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 23 of 38
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+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 24 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
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
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 4 –  Planned for 11/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 25 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  11/28/2017 through 12/25/2017 (28 days), Planned
Day 1, Cycle 5 –  Planned for 11/28/2017
Treatment Plan Information
Reference Information (1)
COLON AND RECTAL CANCER: Andre, et al. Eur J Cancer 1999;35:1343-7.
Reference Information (2)
COLON AND RECTAL CANCER: Tournigand, et al. J Clin Oncol 2004;23:229-37.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 26 of 38
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
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
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
or Urine protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 27 of 38
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 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) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
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
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 28 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:
irinotecan/leucovorin/bevacizumab/fluorouracil for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN,  Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without microscopy,
CEA; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/leucovorin/bevacizumab /fluorouracil for 180 minutes.
Day 3 (Pump Disconnect), Cycle 5 –  Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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 46-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 12/12/2017
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 29 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Hypersensitivity Monitoring (1)
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.
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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 30 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
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
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 31 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Day 17 (Pump Disconnect), Cycle 5 –  Planned for 12/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  12/26/2017 through 1/22/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 12/26/2017
Treatment Plan Information
Reference Information (1)
COLON AND RECTAL CANCER: Andre, et al. Eur J Cancer 1999;35:1343-7.
Reference Information (2)
COLON AND RECTAL CANCER: Tournigand, et al. J Clin Oncol 2004;23:229-37.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 32 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
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
or Urine protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Monitoring Parameters (1)
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 33 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
leucovorin 392 mg in dextrose 5 % 500 mL bag
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 34 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:
irinotecan/leucovorin/bevacizumab/fluorouracil for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN,  Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without microscopy,
CEA; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/leucovorin/bevacizumab /fluorouracil for 180 minutes.
Day 3 (Pump Disconnect), Cycle 6 –  Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 35 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 –  Planned for 1/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 36 of 38
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 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) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
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
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 37 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 6 –  Planned for 1/11/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: bevacizumab 5 mg/kg IV Day 1 and 15, irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on 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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:19:25 PM Page 38 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org