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CSC GI Capecitabine(28D:1-7,15-22) Oxaliplatin(28D:1,15) VER 8-15-17 (HL 380)

CSC GI Capecitabine(28D:1-7,15-22) Oxaliplatin(28D:1,15) VER 8-15-17 (HL 380) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI CAPECITABINE(28D:1-7,15-22)/OXALIPLATIN(28D:1,15) VER: 8-15-17 –  Properties
Pre-Cycle –  8/2/2017 through 8/8/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: oxaliplatin 85 mg/m2 IV Day 1 and 15, capecitabine 1750
mg/m2 by mouth twice daily, Day 1 through 7 and Day 15 through 21; CYCLE LENGTH: 28 days; COURSE: 3 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
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
Cycle 1 –  8/9/2017 through 9/5/2017 (28 days), Planned
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Zztestonc,Jeff J [2507481]
8/9/2017 3:28:22 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

Day 1, Cycle 1 –  Planned for 8/9/2017
Treatment Plan Information
Reference Information (1)
COLON AND RECTAL CANCER: Scheithauer, et al. J of Clin Oncol 2003;21:1307-12.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: oxaliplatin 85 mg/m2 IV Day 1 and 15, capecitabine 1750
mg/m2 by mouth twice daily, Day 1 through 7 and Day 15 through 21; CYCLE LENGTH: 28 days; COURSE: 3 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
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.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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.
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
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Zztestonc,Jeff J [2507481]
8/9/2017 3:28:22 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

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
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
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency 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 7 tabs by mouth 2 times daily. Take on Day 1 through Day 7 and Day 15 through Day 21., 3,500 mg (rounded
from 3,430 mg = 1,750 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 500mg and 150mg.
capecitabine (XELODA) 150 MG tab
Take 23 tabs by mouth 2 times daily. Take on Day 1 through Day 7 and Day 15 through Day 21., 3,450 mg (rounded
from 3,430 mg = 1,750 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 500mg and 150mg.
Follow-Up
DAY 15 FOLLOW-UP
LABS: WBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT:  oxaliplatin for 150 minutes.
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 3:28:22 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

DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST,
ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: oxaliplatin infusion for 150 minutes.
Day 15, Cycle 1 –  Planned for 8/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: oxaliplatin 85 mg/m2 IV Day 1 and 15, capecitabine 1750
mg/m2 by mouth twice daily, Day 1 through 7 and Day 15 through 21; CYCLE LENGTH: 28 days; COURSE: 3 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
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Zztestonc,Jeff J [2507481]
8/9/2017 3:28:22 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

Check for mucositis, irritation of hands or feet, or diarrhea.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken capecitabine and document in a progress note.  Notify authorizing prescriber if patient has
not taken medication as prescribed.
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.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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.
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
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
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Zztestonc,Jeff J [2507481]
8/9/2017 3:28:22 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

oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when
necessary between chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can
occur. For first and second dose, patient should be treated in a location to optimize emergency care.
See Emergency 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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  9/6/2017 through 10/3/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: oxaliplatin 85 mg/m2 IV Day 1 and 15, capecitabine 1750
mg/m2 by mouth twice daily, Day 1 through 7 and Day 15 through 21; CYCLE LENGTH: 28 days; COURSE: 3 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
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Zztestonc,Jeff J [2507481]
8/9/2017 3:28:22 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

AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken capecitabine and document in a progress note.  Notify authorizing prescriber if patient has
not taken medication as prescribed.
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.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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.
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
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Jeff J [2507481]
8/9/2017 3:28:22 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

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
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency 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 7 tabs by mouth 2 times daily. Take on Day 1 through Day 7 and Day 15 through Day 21., 3,500 mg (rounded
from 3,430 mg = 1,750 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 500mg and 150mg.
capecitabine (XELODA) 150 MG tab
Take 23 tabs by mouth 2 times daily. Take on Day 1 through Day 7 and Day 15 through Day 21., 3,450 mg (rounded
from 3,430 mg = 1,750 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 500mg and 150mg.
Follow-Up
DAY 15 FOLLOW-UP
LABS: WBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT:  oxaliplatin for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: oxaliplatin infusion for 150 minutes.
Day 15, Cycle 2 –  Planned for 9/20/2017
Treatment Plan Information
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 3:28:22 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

Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: oxaliplatin 85 mg/m2 IV Day 1 and 15,
capecitabine 1750 mg/m2 by mouth twice daily, Day 1 through 7 and Day 15 through 21; CYCLE
LENGTH: 28 days; COURSE: 3 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken capecitabine and document in a progress note.  Notify authorizing prescriber if patient has
not taken medication as prescribed.
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.
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Zztestonc,Jeff J [2507481]
8/9/2017 3:28:22 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

Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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.
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
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
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency 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).
Follow-Up
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Zztestonc,Jeff J [2507481]
8/9/2017 3:28:22 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

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  10/4/2017 through 10/31/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 10/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: oxaliplatin 85 mg/m2 IV Day 1 and 15, capecitabine 1750
mg/m2 by mouth twice daily, Day 1 through 7 and Day 15 through 21; CYCLE LENGTH: 28 days; COURSE: 3 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
Treatment Conditions
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Zztestonc,Jeff J [2507481]
8/9/2017 3:28:22 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

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.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken capecitabine and document in a progress note.  Notify authorizing prescriber if patient has
not taken medication as prescribed.
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.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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.
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
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
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Zztestonc,Jeff J [2507481]
8/9/2017 3:28:22 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

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
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency 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 7 tabs by mouth 2 times daily. Take on Day 1 through Day 7 and Day 15 through Day 21., 3,500 mg (rounded
from 3,430 mg = 1,750 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 500mg and 150mg.
capecitabine (XELODA) 150 MG tab
Take 23 tabs by mouth 2 times daily. Take on Day 1 through Day 7 and Day 15 through Day 21., 3,450 mg (rounded
from 3,430 mg = 1,750 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 500mg and 150mg.
Follow-Up
DAY 15 FOLLOW-UP
LABS: WBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT:  oxaliplatin for 150 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: oxaliplatin infusion for 150 minutes.
Day 15, Cycle 3 –  Planned for 10/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: oxaliplatin 85 mg/m2 IV Day 1 and 15, capecitabine 1750
mg/m2 by mouth twice daily, Day 1 through 7 and Day 15 through 21; CYCLE LENGTH: 28 days; COURSE: 3 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.
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 3:28:22 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

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken capecitabine and document in a progress note.  Notify authorizing prescriber if patient has
not taken medication as prescribed.
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.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
8/9/2017 3:28:22 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

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
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
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency 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).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/9/2017 3:28:22 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