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CSC GI Cisplatin(21D:1) Docetaxel(21D:1) Fluorouracil(21D:1-5) VER 8-15-17 (HL 428)

CSC GI Cisplatin(21D:1) Docetaxel(21D:1) Fluorouracil(21D:1-5) VER 8-15-17 (HL 428) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI CISPLATIN(21D:1)/DOCETAXEL(21D:1)/FLUOROURACIL(21D:1-5) VER: 8-15-17 –  Properties
Pre-Cycle –  8/1/2017 through 8/7/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric Cancer (Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV on Day 1, CISplatin 75 mg/m2 IV on Day 1,
fluorouracil 750 mg/m2/day administered as a continuous infusion IV over 120 hours on Day 1 through 5 (Total dose =
3750 mg/m2 IV over 120 hours per home infusion); CYCLE LENGTH: 21 days; COURSE: 4 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
MAGNESIUM
Expected: S Approximate, Expires: S+365, Routine
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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

Starting the AM before chemo, take 2 tabs by mouth 2X daily for 3 days, then 2 tablets 1X daily for 2 days., Disp-50 tab,
R-1, starting S, Local Printer
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for two days following chemotherapy., 80 mg, Disp-2 cap, 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 –  8/8/2017 through 8/28/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 8/8/2017
Treatment Plan Information
Reference Information (1)
GASTRIC CANCER: Ajani J, et al. J Clin Oncol 2005;23:5660-67.
Treatment Plan Summary
DISEASE: Gastric Cancer (Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV on Day 1, CISplatin 75 mg/m2 IV on Day 1,
fluorouracil 750 mg/m2/day administered as a continuous infusion IV over 120 hours on Day 1 through 5 (Total dose =
3750 mg/m2 IV over 120 hours per home infusion); CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine greater than ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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

** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose.  RN to do the same for second dose if
adverse reaction during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
DOCEtaxel (TAXOTERE) 148 mg in dextrose 5 % 250 mL non-PVC bag
148 mg (rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications. In non-PVC bag. Infuse through non PVC tubing.
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 to 90 minutes.
fluorouracil (ADRUCIL) home infusion bag 7,350 mg
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Five Day Infusion: Fluorouracil Dose = 750 mg/m2/DAY administered as a single continuous infusion IV over 120 hours.
(Total dose = 3750 mg/m2 IV over 120 hours).
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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

Follow-Up
DAY 6 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel, CISplatin, fluorouracil for 210 minutes.
Day 6 (Pump Disconnect), Cycle 1 –  Planned for 8/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric Cancer (Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV on Day 1, CISplatin 75 mg/m2 IV on Day 1,
fluorouracil 750 mg/m2/day administered as a continuous infusion IV over 120 hours on Day 1 through 5 (Total dose =
3750 mg/m2 IV over 120 hours per home infusion); CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 120-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  8/29/2017 through 9/18/2017 (21 days), Planned
Day 1, Cycle 2 –  Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric Cancer (Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV on Day 1, CISplatin 75 mg/m2 IV on Day 1,
fluorouracil 750 mg/m2/day administered as a continuous infusion IV over 120 hours on Day 1 through 5 (Total dose =
3750 mg/m2 IV over 120 hours per home infusion); CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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

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
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine greater than ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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

Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose.  RN to do the same for
second dose if adverse reaction during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
DOCEtaxel (TAXOTERE) 148 mg in dextrose 5 % 250 mL non-PVC bag
148 mg (rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications. In non-PVC bag. Infuse through non PVC tubing.
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 to 90 minutes.
fluorouracil (ADRUCIL) home infusion bag 7,350 mg
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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

Five Day Infusion: Fluorouracil Dose = 750 mg/m2/DAY administered as a single continuous infusion IV over 120 hours.
(Total dose = 3750 mg/m2 IV over 120 hours).
Follow-Up
DAY 6 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel, CISplatin, fluorouracil for 210 minutes.
Day 6 (Pump Disconnect), Cycle 2 –  Planned for 9/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric Cancer (Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV on Day 1, CISplatin 75 mg/m2 IV on Day 1,
fluorouracil 750 mg/m2/day administered as a continuous infusion IV over 120 hours on Day 1 through 5 (Total dose =
3750 mg/m2 IV over 120 hours per home infusion); CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 120-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  9/19/2017 through 10/9/2017 (21 days), Planned
Day 1, Cycle 3 –  Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric Cancer (Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV on Day 1, CISplatin 75 mg/m2 IV on Day 1,
fluorouracil 750 mg/m2/day administered as a continuous infusion IV over 120 hours on Day 1 through 5 (Total dose =
3750 mg/m2 IV over 120 hours per home infusion); CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Consent
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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 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
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine greater than ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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

Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose.  RN to do the same for second dose if
adverse reaction during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
DOCEtaxel (TAXOTERE) 148 mg in dextrose 5 % 250 mL non-PVC bag
148 mg (rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications. In non-PVC bag. Infuse through non PVC tubing.
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 to 90 minutes.
fluorouracil (ADRUCIL) home infusion bag 7,350 mg
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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

7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Five Day Infusion: Fluorouracil Dose = 750 mg/m2/DAY administered as a single continuous infusion IV
over 120 hours. (Total dose = 3750 mg/m2 IV over 120 hours).
Follow-Up
DAY 6 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel, CISplatin, fluorouracil for 210 minutes.
Day 6 (Pump Disconnect), Cycle 3 –  Planned for 9/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric Cancer (Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV on Day 1, CISplatin 75 mg/m2 IV on Day 1,
fluorouracil 750 mg/m2/day administered as a continuous infusion IV over 120 hours on Day 1 through 5 (Total dose =
3750 mg/m2 IV over 120 hours per home infusion); CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 120-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  10/10/2017 through 10/30/2017 (21 days), Planned
Day 1, Cycle 4 –  Planned for 10/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric Cancer (Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV on Day 1, CISplatin 75 mg/m2 IV on Day 1,
fluorouracil 750 mg/m2/day administered as a continuous infusion IV over 120 hours on Day 1 through 5 (Total dose =
3750 mg/m2 IV over 120 hours per home infusion); CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Consent
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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

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
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine greater than ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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

Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose.  RN to do the same for second dose if
adverse reaction during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
DOCEtaxel (TAXOTERE) 148 mg in dextrose 5 % 250 mL non-PVC bag
148 mg (rounded from 147 mg = 75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications. In non-PVC bag. Infuse through non PVC tubing.
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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

147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 to 90 minutes.
fluorouracil (ADRUCIL) home infusion bag 7,350 mg
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Five Day Infusion: Fluorouracil Dose = 750 mg/m2/DAY administered as a single continuous infusion IV over 120 hours.
(Total dose = 3750 mg/m2 IV over 120 hours).
Follow-Up
DAY 6 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel, CISplatin, fluorouracil for 210 minutes.
Day 6 (Pump Disconnect), Cycle 4 –  Planned for 10/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric Cancer (Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV on Day 1, CISplatin 75 mg/m2 IV on Day 1,
fluorouracil 750 mg/m2/day administered as a continuous infusion IV over 120 hours on Day 1 through 5 (Total dose =
3750 mg/m2 IV over 120 hours per home infusion); CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 120-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:29:17 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