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CSC GI Capecitabine(21D:1-21) Epirubicin(21D:1) Oxaliplatin(21D:1) VER 8-15-17 (HL 1989)

CSC GI Capecitabine(21D:1-21) Epirubicin(21D:1) Oxaliplatin(21D:1) VER 8-15-17 (HL 1989) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI CAPECITABINE(21D:1-21)/EPIRUBICIN(21D:1)/OXALIPLATIN(21D:1) 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: Esophageal Cancer (Advanced), GE Junction Cancer (Advanced), Gastric Cancer (Advanced); THERAPY:
epirubicin 50 mg/m2 IV Day 1, oxaliplatin 130 mg/m2 IV Day 1, capecitabine 625 mg/m2 by mouth twice daily Day 1
through 21; CYCLE LENGTH: 21 days; COURSE: Indefinite or until disease progression, surgical resection or toxicity
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Normal, Routine
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
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy., 8 mg, Disp-18 tab, R-1, 1 X DAILY
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
Reference Information (1)
ESOPHAGEAL/GE JUNCTION/GASTRIC CANCER: Cunningham D, et al. N Engl J Med 2008;358(1):36-46.
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 1 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DISEASE: Esophageal Cancer (Advanced), GE Junction Cancer (Advanced), Gastric Cancer (Advanced);
THERAPY: epirubicin 50 mg/m2 IV Day 1, oxaliplatin 130 mg/m2 IV Day 1, capecitabine 625 mg/m2 by
mouth twice daily Day 1 through 21; CYCLE LENGTH: 21 days; COURSE: Indefinite or until disease
progression, surgical resection or toxicity
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine
greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 50 mL/min or Total Bilirubin greater than or equal
to 1.2 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 2 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
epirubicin (ELLENCE) injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
**vesicant** Give over 3-5 minutes through running IV line.
oxaliplatin (ELOXATIN) 255 mg in dextrose 5 % 250 mL bag
255 mg (rounded from 254.8 mg = 130 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Administer over 120 minutes. Incompatible with Sodium Chloride.
Allow adequate flushing with Dextrose 5% in Water when necessary between chemotherapy treatment medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (dispensed on Day
1 of each cycle).
Take Home Medications
capecitabine (XELODA) 150 MG tab
Take  by mouth 2 times daily. Take on Day 1 through 21. Take with food., R-0, 2 X DAILY starting S, Local Printer
Dose = 625 mg/m2 by mouth twice daily. Round dose to the nearest tablet size (150 mg and 500 mg tablets available).
capecitabine (XELODA) 500 MG tab
Take  by mouth 2 times daily. Take on Day 1 through 21. Take with food., R-0, 2 X DAILY starting S, Local Printer
Dose = 625 mg/m2 by mouth twice daily. Round dose to the nearest tablet size (150 mg and 500 mg tablets available).
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
done locally), Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
epirubicin and oxaliplatin for 150 minutes
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
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 3 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DISEASE: Esophageal Cancer (Advanced), GE Junction Cancer (Advanced), Gastric Cancer (Advanced); THERAPY:
epirubicin 50 mg/m2 IV Day 1, oxaliplatin 130 mg/m2 IV Day 1, capecitabine 625 mg/m2 by mouth twice daily Day 1
through 21; CYCLE LENGTH: 21 days; COURSE: Indefinite or until disease progression, surgical resection or toxicity
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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine
greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 50 mL/min or Total Bilirubin greater than or equal
to 1.2 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 4 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
epirubicin (ELLENCE) injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
**vesicant** Give over 3-5 minutes through running IV line.
oxaliplatin (ELOXATIN) 255 mg in dextrose 5 % 250 mL bag
255 mg (rounded from 254.8 mg = 130 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Administer over 120 minutes. Incompatible with Sodium Chloride.
Allow adequate flushing with Dextrose 5% in Water when necessary between chemotherapy treatment medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (dispensed on Day
1 of each cycle).
Take Home Medications
capecitabine (XELODA) 150 MG tab
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 5 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Take  by mouth 2 times daily. Take on Day 1 through 21. Take with food., R-0, 2 X DAILY starting S, Local Printer
Dose = 625 mg/m2 by mouth twice daily. Round dose to the nearest tablet size (150 mg and 500 mg tablets available).
capecitabine (XELODA) 500 MG tab
Take  by mouth 2 times daily. Take on Day 1 through 21. Take with food., R-0, 2 X DAILY starting S, Local Printer
Dose = 625 mg/m2 by mouth twice daily. Round dose to the nearest tablet size (150 mg and 500 mg tablets available).
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
done locally), Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
epirubicin and oxaliplatin for 150 minutes
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: Esophageal Cancer (Advanced), GE Junction Cancer (Advanced), Gastric Cancer (Advanced); THERAPY:
epirubicin 50 mg/m2 IV Day 1, oxaliplatin 130 mg/m2 IV Day 1, capecitabine 625 mg/m2 by mouth twice daily Day 1
through 21; CYCLE LENGTH: 21 days; COURSE: Indefinite or until disease progression, surgical resection or toxicity
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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 6 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine
greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 50 mL/min or Total Bilirubin greater than or equal
to 1.2 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 7 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
epirubicin (ELLENCE) injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
**vesicant** Give over 3-5 minutes through running IV line.
oxaliplatin (ELOXATIN) 255 mg in dextrose 5 % 250 mL bag
255 mg (rounded from 254.8 mg = 130 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Administer over 120 minutes. Incompatible with Sodium Chloride.
Allow adequate flushing with Dextrose 5% in Water when necessary between chemotherapy treatment medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (dispensed on Day
1 of each cycle).
Take Home Medications
capecitabine (XELODA) 150 MG tab
Take  by mouth 2 times daily. Take on Day 1 through 21. Take with food., R-0, 2 X DAILY starting S, Local Printer
Dose = 625 mg/m2 by mouth twice daily. Round dose to the nearest tablet size (150 mg and 500 mg tablets available).
capecitabine (XELODA) 500 MG tab
Take  by mouth 2 times daily. Take on Day 1 through 21. Take with food., R-0, 2 X DAILY starting S, Local Printer
Dose = 625 mg/m2 by mouth twice daily. Round dose to the nearest tablet size (150 mg and 500 mg tablets available).
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
done locally), Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
epirubicin and oxaliplatin for 150 minutes
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: Esophageal Cancer (Advanced), GE Junction Cancer (Advanced), Gastric Cancer (Advanced); THERAPY:
epirubicin 50 mg/m2 IV Day 1, oxaliplatin 130 mg/m2 IV Day 1, capecitabine 625 mg/m2 by mouth twice daily Day 1
through 21; CYCLE LENGTH: 21 days; COURSE: Indefinite or until disease progression, surgical resection or toxicity
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, Normal, Routine
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 8 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine
greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 50 mL/min or Total Bilirubin greater than or equal
to 1.2 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 9 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
epirubicin (ELLENCE) injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
**vesicant** Give over 3-5 minutes through running IV line.
oxaliplatin (ELOXATIN) 255 mg in dextrose 5 % 250 mL bag
255 mg (rounded from 254.8 mg = 130 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Administer over 120 minutes. Incompatible with Sodium Chloride.
Allow adequate flushing with Dextrose 5% in Water when necessary between chemotherapy treatment medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (dispensed on Day
1 of each cycle).
Take Home Medications
capecitabine (XELODA) 150 MG tab
Take  by mouth 2 times daily. Take on Day 1 through 21. Take with food., R-0, 2 X DAILY starting S, Local Printer
Dose = 625 mg/m2 by mouth twice daily. Round dose to the nearest tablet size (150 mg and 500 mg tablets available).
capecitabine (XELODA) 500 MG tab
Take  by mouth 2 times daily. Take on Day 1 through 21. Take with food., R-0, 2 X DAILY starting S, Local Printer
Dose = 625 mg/m2 by mouth twice daily. Round dose to the nearest tablet size (150 mg and 500 mg tablets available).
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
done locally), Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
epirubicin and oxaliplatin for 150 minutes
Cycle 5 –  11/1/2017 through 11/21/2017 (21 days), Planned
Day 1, Cycle 5 –  Planned for 11/1/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 10 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Esophageal Cancer (Advanced), GE Junction Cancer (Advanced), Gastric Cancer (Advanced);
THERAPY: epirubicin 50 mg/m2 IV Day 1, oxaliplatin 130 mg/m2 IV Day 1, capecitabine 625 mg/m2 by
mouth twice daily Day 1 through 21; CYCLE LENGTH: 21 days; COURSE: Indefinite or until disease
progression, surgical resection or toxicity
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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine
greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 50 mL/min or Total Bilirubin greater than or equal
to 1.2 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 11 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
dextrose 5 % 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
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
epirubicin (ELLENCE) injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
**vesicant** Give over 3-5 minutes through running IV line.
oxaliplatin (ELOXATIN) 255 mg in dextrose 5 % 250 mL bag
255 mg (rounded from 254.8 mg = 130 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Administer over 120 minutes. Incompatible with Sodium Chloride.
Allow adequate flushing with Dextrose 5% in Water when necessary between chemotherapy treatment medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (dispensed on Day
1 of each cycle).
Take Home Medications
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 12 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

capecitabine (XELODA) 150 MG tab
Take  by mouth 2 times daily. Take on Day 1 through 21. Take with food., R-0, 2 X DAILY starting S,
Local Printer
Dose = 625 mg/m2 by mouth twice daily. Round dose to the nearest tablet size (150 mg and 500 mg
tablets available).
capecitabine (XELODA) 500 MG tab
Take  by mouth 2 times daily. Take on Day 1 through 21. Take with food., R-0, 2 X DAILY starting S, Local Printer
Dose = 625 mg/m2 by mouth twice daily. Round dose to the nearest tablet size (150 mg and 500 mg tablets available).
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
done locally), Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
epirubicin and oxaliplatin for 150 minutes
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: Esophageal Cancer (Advanced), GE Junction Cancer (Advanced), Gastric Cancer (Advanced); THERAPY:
epirubicin 50 mg/m2 IV Day 1, oxaliplatin 130 mg/m2 IV Day 1, capecitabine 625 mg/m2 by mouth twice daily Day 1
through 21; CYCLE LENGTH: 21 days; COURSE: Indefinite or until disease progression, surgical resection or toxicity
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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 13 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine
greater than or equal to 1.5 mg/dL or Creatinine Clearance less than 50 mL/min or Total Bilirubin greater than or equal
to 1.2 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 14 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
epirubicin (ELLENCE) injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
**vesicant** Give over 3-5 minutes through running IV line.
oxaliplatin (ELOXATIN) 255 mg in dextrose 5 % 250 mL bag
255 mg (rounded from 254.8 mg = 130 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Administer over 120 minutes. Incompatible with Sodium Chloride.
Allow adequate flushing with Dextrose 5% in Water when necessary between chemotherapy treatment medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (dispensed on Day
1 of each cycle).
Take Home Medications
capecitabine (XELODA) 150 MG tab
Take  by mouth 2 times daily. Take on Day 1 through 21. Take with food., R-0, 2 X DAILY starting S, Local Printer
Dose = 625 mg/m2 by mouth twice daily. Round dose to the nearest tablet size (150 mg and 500 mg tablets available).
capecitabine (XELODA) 500 MG tab
Take  by mouth 2 times daily. Take on Day 1 through 21. Take with food., R-0, 2 X DAILY starting S, Local Printer
Dose = 625 mg/m2 by mouth twice daily. Round dose to the nearest tablet size (150 mg and 500 mg tablets available).
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
done locally), Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
epirubicin and oxaliplatin for 150 minutes
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Zztestonc,Jeff J [2507481]
8/9/2017 3:19:55 PM Page 15 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org