/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/gi/,

/clinical/cckm-tools/content/beacon-protocols/gi/name-96642-en.cckm

201708223

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100

UWHC,UWMF,

Tools,

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

CSC GI Cisplatin(21D:1,8) Irinotecan(21D:1,8) VER 8-15-17 (HL 411)

CSC GI Cisplatin(21D:1,8) Irinotecan(21D:1,8) VER 8-15-17 (HL 411) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI CISPLATIN(21D:1,8)/IRINOTECAN(21D:1,8) 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: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
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
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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 1 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8
HOURS PRN starting S, Local Printer
loperamide 2 MG cap
Take 2 tab by mouth with 1st loose stool followed by 1 tab every 2h or 2 tab every 4h until no diarrhea x12h. Max
dose=8 tab/day, Disp-30 cap, R-5, starting S, Local Printer
Counsel patient to purchase over the counter if not covered by insurance and provide instructions for use.
Cycle 1 –  8/8/2017 through 8/28/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 8/8/2017
Treatment Plan Information
Reference Information (1)
ESOPHAGUS CANCER: Ilson, DH, et al. J Clin Oncol 1999;17:3270-5.
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, 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.
Nursing Procedure, Assessment and Monitoring
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.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 2 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 127.4 mg in dextrose 5 % 250 mL bag
127.4 mg (65 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
CISplatin (PLATINOL) 59 mg in sodium chloride 0.9 % 1,000 mL bag
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Potassium, Magnesium; CHEMOTHERAPY ROOM
APPOINTMENT:  CISplatin and irinotecan for 150 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT:  CISplatin and irinotecan for 150 minutes.
Day 8, Cycle 1 –  Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
IV Access
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 3 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 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.
Nursing Procedure, Assessment and Monitoring
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.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 4 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 127.4 mg in dextrose 5 % 250 mL bag
127.4 mg (65 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
CISplatin (PLATINOL) 59 mg in sodium chloride 0.9 % 1,000 mL bag
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 5 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+14 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.
Nursing Procedure, Assessment and Monitoring
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.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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]
8/8/2017 2:10:10 PM Page 6 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 127.4 mg in dextrose 5 % 250 mL bag
127.4 mg (65 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
CISplatin (PLATINOL) 59 mg in sodium chloride 0.9 % 1,000 mL bag
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Potassium, Magnesium; CHEMOTHERAPY ROOM
APPOINTMENT:  CISplatin and irinotecan for 150 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT:  CISplatin and irinotecan for 150 minutes.
Day 8, Cycle 2 –  Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 7 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 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.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 8 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 127.4 mg in dextrose 5 % 250 mL bag
127.4 mg (65 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
CISplatin (PLATINOL) 59 mg in sodium chloride 0.9 % 1,000 mL bag
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 9 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Routine
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
MAGNESIUM
Expected: S+14 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.
Nursing Procedure, Assessment and Monitoring
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.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 10 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 127.4 mg in dextrose 5 % 250 mL bag
127.4 mg (65 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
CISplatin (PLATINOL) 59 mg in sodium chloride 0.9 % 1,000 mL bag
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Potassium, Magnesium; CHEMOTHERAPY ROOM
APPOINTMENT:  CISplatin and irinotecan for 150 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT:  CISplatin and irinotecan for 150 minutes.
Day 8, Cycle 3 –  Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 11 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 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.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
dexamethasone (DECADRON) tab 12 mg
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 12 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 127.4 mg in dextrose 5 % 250 mL bag
127.4 mg (65 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
CISplatin (PLATINOL) 59 mg in sodium chloride 0.9 % 1,000 mL bag
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 13 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Routine
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
MAGNESIUM
Expected: S+14 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.
Nursing Procedure, Assessment and Monitoring
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.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 14 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 127.4 mg in dextrose 5 % 250 mL bag
127.4 mg (65 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
CISplatin (PLATINOL) 59 mg in sodium chloride 0.9 % 1,000 mL bag
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Potassium, Magnesium; CHEMOTHERAPY ROOM
APPOINTMENT:  CISplatin and irinotecan for 150 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT:  CISplatin and irinotecan for 150 minutes.
Day 8, Cycle 4 –  Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 15 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 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.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 127.4 mg in dextrose 5 % 250 mL bag
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 16 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

127.4 mg (65 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 90 minutes.
CISplatin (PLATINOL) 59 mg in sodium chloride 0.9 % 1,000 mL bag
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  10/31/2017 through 11/20/2017 (21 days), Planned
Day 1, Cycle 5 –  Planned for 10/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 17 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+14 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.
Nursing Procedure, Assessment and Monitoring
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.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 18 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 127.4 mg in dextrose 5 % 250 mL bag
127.4 mg (65 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
CISplatin (PLATINOL) 59 mg in sodium chloride 0.9 % 1,000 mL bag
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Potassium, Magnesium; CHEMOTHERAPY ROOM
APPOINTMENT:  CISplatin and irinotecan for 150 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT:  CISplatin and irinotecan for 150 minutes.
Day 8, Cycle 5 –  Planned for 11/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 19 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+7 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.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 127.4 mg in dextrose 5 % 250 mL bag
127.4 mg (65 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
CISplatin (PLATINOL) 59 mg in sodium chloride 0.9 % 1,000 mL bag
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 20 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, ONCE, 1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  11/21/2017 through 12/11/2017 (21 days), Planned
Day 1, Cycle 6 –  Planned for 11/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 21 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+14 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.
Nursing Procedure, Assessment and Monitoring
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.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 22 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

irinotecan CONVENTIONAL (CAMPTOSAR) 127.4 mg in dextrose 5 % 250 mL bag
127.4 mg (65 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
CISplatin (PLATINOL) 59 mg in sodium chloride 0.9 % 1,000 mL bag
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Potassium, Magnesium; CHEMOTHERAPY ROOM
APPOINTMENT:  CISplatin and irinotecan for 150 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT:  CISplatin and irinotecan for 150 minutes.
Day 8, Cycle 6 –  Planned for 11/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction Cancer (Advanced); THERAPY: irinotecan 65 mg/m2 IV Day 1 and 8,
CISplatin 30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until progression.
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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 23 of 25
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, 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.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 127.4 mg in dextrose 5 % 250 mL bag
127.4 mg (65 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
CISplatin (PLATINOL) 59 mg in sodium chloride 0.9 % 1,000 mL bag
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
For 60 to 90 minutes.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 24 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:10:10 PM Page 25 of 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org