/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-96629-en.cckm

201708223

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100

UWHC,UWMF,

Tools,

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

CSC GI Capecitabine 1250mg/M2(21D:1-14) VER 8-15-17 (HL 400)

CSC GI Capecitabine 1250mg/M2(21D:1-14) VER 8-15-17 (HL 400) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI CAPECITABINE 1250MG/M2(21D:1-14) VER: 8-15-17 –  Properties
Pre-Cycle –  8/2/2017 through 8/8/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colorectal (Adjuvant/Advanced) and Rectal Cancer (Advanced) without XRT; THERAPY: capecitabine 1250
mg/m2 by mouth twice daily, Day 1 though 14 followed by 7 days rest; CYCLE LENGTH: 21 days; COURSE: Adjuvant: 8
cycles (6 months); Advanced: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
Cycle 1 –  8/9/2017 through 8/29/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 8/9/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 1 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Reference Information (1)
COLON CANCER (Adjuvant) : Twelves C, et al. N Engl J Med 2005;352:2696-701.
Reference Information (2)
COLON CANCER (Advanced) : Hoff P, et al. J of Clin Oncol 2001;19:2282-92.
Treatment Plan Summary
DISEASE: Colorectal (Adjuvant/Advanced) and Rectal Cancer (Advanced) without XRT; THERAPY: capecitabine 1250
mg/m2 by mouth twice daily, Day 1 though 14 followed by 7 days rest; CYCLE LENGTH: 21 days; COURSE: Adjuvant: 8
cycles (6 months); Advanced: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine and to call with concerns.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications
capecitabine (XELODA) 500 MG tab
Take 5 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,500 mg (rounded from 2,450 mg = 1,250 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
capecitabine (XELODA) 150 MG tab
Take 16 tabs by mouth 2 times daily. Take on Day 1 through14., 2,400 mg (rounded from 2,450 mg = 1,250 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
Follow-Up
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 2 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be
done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase.
Cycle 2 –  8/30/2017 through 9/19/2017 (21 days), Planned
Day 1, Cycle 2 –  Planned for 8/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colorectal (Adjuvant/Advanced) and Rectal Cancer (Advanced) without XRT; THERAPY: capecitabine 1250
mg/m2 by mouth twice daily, Day 1 though 14 followed by 7 days rest; CYCLE LENGTH: 21 days; COURSE: Adjuvant: 8
cycles (6 months); Advanced: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 3 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine and to call with concerns.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications
capecitabine (XELODA) 500 MG tab
Take 5 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,500 mg (rounded from 2,450 mg = 1,250 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
capecitabine (XELODA) 150 MG tab
Take 16 tabs by mouth 2 times daily. Take on Day 1 through14., 2,400 mg (rounded from 2,450 mg = 1,250 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase.
Cycle 3 –  9/20/2017 through 10/10/2017 (21 days), Planned
Day 1, Cycle 3 –  Planned for 9/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colorectal (Adjuvant/Advanced) and Rectal Cancer (Advanced) without XRT; THERAPY: capecitabine 1250
mg/m2 by mouth twice daily, Day 1 though 14 followed by 7 days rest; CYCLE LENGTH: 21 days; COURSE: Adjuvant: 8
cycles (6 months); Advanced: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 4 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine and to call with concerns.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications
capecitabine (XELODA) 500 MG tab
Take 5 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,500 mg (rounded from 2,450 mg = 1,250 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
capecitabine (XELODA) 150 MG tab
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 5 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Take 16 tabs by mouth 2 times daily. Take on Day 1 through14., 2,400 mg (rounded from 2,450 mg = 1,250 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase.
Cycle 4 –  10/11/2017 through 10/31/2017 (21 days), Planned
Day 1, Cycle 4 –  Planned for 10/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colorectal (Adjuvant/Advanced) and Rectal Cancer (Advanced) without XRT; THERAPY: capecitabine 1250
mg/m2 by mouth twice daily, Day 1 though 14 followed by 7 days rest; CYCLE LENGTH: 21 days; COURSE: Adjuvant: 8
cycles (6 months); Advanced: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 6 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine and to call with concerns.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications
capecitabine (XELODA) 500 MG tab
Take 5 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,500 mg (rounded from 2,450 mg = 1,250 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
capecitabine (XELODA) 150 MG tab
Take 16 tabs by mouth 2 times daily. Take on Day 1 through14., 2,400 mg (rounded from 2,450 mg = 1,250 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase.
Cycle 5 –  11/1/2017 through 11/21/2017 (21 days), Planned
Day 1, Cycle 5 –  Planned for 11/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colorectal (Adjuvant/Advanced) and Rectal Cancer (Advanced) without XRT; THERAPY: capecitabine 1250
mg/m2 by mouth twice daily, Day 1 though 14 followed by 7 days rest; CYCLE LENGTH: 21 days; COURSE: Adjuvant: 8
cycles (6 months); Advanced: until disease progression
Consent
Verify Consent
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
Actions
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 7 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine and to call with concerns.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications
capecitabine (XELODA) 500 MG tab
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 8 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Take 5 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,500 mg (rounded from 2,450 mg = 1,250 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
capecitabine (XELODA) 150 MG tab
Take 16 tabs by mouth 2 times daily. Take on Day 1 through14., 2,400 mg (rounded from 2,450 mg = 1,250 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase.
Cycle 6 –  11/22/2017 through 12/12/2017 (21 days), Planned
Day 1, Cycle 6 –  Planned for 11/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colorectal (Adjuvant/Advanced) and Rectal Cancer (Advanced) without XRT; THERAPY: capecitabine 1250
mg/m2 by mouth twice daily, Day 1 though 14 followed by 7 days rest; CYCLE LENGTH: 21 days; COURSE: Adjuvant: 8
cycles (6 months); Advanced: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 9 of 13
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+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine and to call with concerns.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications
capecitabine (XELODA) 500 MG tab
Take 5 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,500 mg (rounded from 2,450 mg = 1,250 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
capecitabine (XELODA) 150 MG tab
Take 16 tabs by mouth 2 times daily. Take on Day 1 through14., 2,400 mg (rounded from 2,450 mg = 1,250 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase.
Cycle 7 –  12/13/2017 through 1/2/2018 (21 days), Planned
Day 1, Cycle 7 –  Planned for 12/13/2017
Treatment Plan Information
Treatment Plan Summary
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 10 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DISEASE: Colorectal (Adjuvant/Advanced) and Rectal Cancer (Advanced) without XRT; THERAPY:
capecitabine 1250 mg/m2 by mouth twice daily, Day 1 though 14 followed by 7 days rest; CYCLE
LENGTH: 21 days; COURSE: Adjuvant: 8 cycles (6 months); Advanced: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine and to call with concerns.
Treatment Medications
See Take Home Medication(s)
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 11 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): capecitabine
(Dispensed Day 1 of each cycle).
Take Home Medications
capecitabine (XELODA) 500 MG tab
Take 5 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,500 mg (rounded from 2,450 mg = 1,250 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
capecitabine (XELODA) 150 MG tab
Take 16 tabs by mouth 2 times daily. Take on Day 1 through14., 2,400 mg (rounded from 2,450 mg = 1,250 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase.
Cycle 8 –  1/3/2018 through 1/23/2018 (21 days), Planned
Day 1, Cycle 8 –  Planned for 1/3/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colorectal (Adjuvant/Advanced) and Rectal Cancer (Advanced) without XRT; THERAPY: capecitabine 1250
mg/m2 by mouth twice daily, Day 1 though 14 followed by 7 days rest; CYCLE LENGTH: 21 days; COURSE: Adjuvant: 8
cycles (6 months); Advanced: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 12 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine and to call with concerns.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Take Home Medications
capecitabine (XELODA) 500 MG tab
Take 5 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,500 mg (rounded from 2,450 mg = 1,250 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
capecitabine (XELODA) 150 MG tab
Take 16 tabs by mouth 2 times daily. Take on Day 1 through14., 2,400 mg (rounded from 2,450 mg = 1,250 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 150mg and 500mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/9/2017 3:11:49 PM Page 13 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org