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CSC GI Concurrent XRT Fluorouracil(28:D1-4) Mitomycin(28:D1) VER 8-15-17 (HL 562)

CSC GI Concurrent XRT Fluorouracil(28:D1-4) Mitomycin(28:D1) VER 8-15-17 (HL 562) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI CONCURRENT XRT FLUOROURACIL(28D:1-4)/MITOMYCIN(28D:1) VER: 8-15-17 –  Properties
Pre-Cycle –  8/3/2017 through 8/9/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anal Cancer (Adjuvant); THERAPY: mitomycin 10 mg/m2 IV Day 1, fluorouracil 1000 mg/m2/day administered
as a continuous infusion IV over 96 hours on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per
home infusion); CYCLE LENGTH: 28 days; COURSE: 2 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
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
dexamethasone (DECADRON) 4 MG tab
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Zztestonc,Jeff J [2507481]
8/10/2017 8:40:28 AM Page 1 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-12 tab, R-0, 1 X DAILY
starting S, Local Printer
Cycle 1 –  8/10/2017 through 9/6/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/10/2017
Treatment Plan Information
Reference Information (1)
ANAL CANCER: Ajani JA, et al. J Clin Oncol 2006;24:4009.
Treatment Plan Summary
DISEASE: Anal Cancer (Adjuvant); THERAPY: mitomycin 10 mg/m2 IV Day 1, fluorouracil 1000 mg/m2/day administered
as a continuous infusion IV over 96 hours on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per
home infusion); CYCLE LENGTH: 28 days; COURSE: 2 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
Page Or Call ___________
Notify Home infusion provider.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
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.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:40:28 AM Page 2 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % 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
Treatment Medications
mitomycin (MUTAMYCIN) injection 19.6 mg
19.6 mg (10 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-10 Minutes
IV side arm push. ** Vesicant **
fluorouracil (ADRUCIL) home infusion bag 7,840 mg
7,840 mg (4,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Four Day Infusion: Fluorouracil Dose = 1000 mg/m2/Day administered as a single continuous infusion IV over 96 hours.
(Total dose = 4000 mg/m2 IV over 96 hours).
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: fluorouracil (pump connect)/mitomycin for 60 minutes.
Day 5 (Pump Disconnect), Cycle 1 –  Planned for 8/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anal Cancer (Adjuvant); THERAPY: mitomycin 10 mg/m2 IV Day 1, fluorouracil 1000 mg/m2/day administered
as a continuous infusion IV over 96 hours on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per
home infusion); CYCLE LENGTH: 28 days; COURSE: 2 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.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:40:28 AM Page 3 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  9/7/2017 through 10/4/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anal Cancer (Adjuvant); THERAPY: mitomycin 10 mg/m2 IV Day 1, fluorouracil 1000 mg/m2/day administered
as a continuous infusion IV over 96 hours on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per
home infusion); CYCLE LENGTH: 28 days; COURSE: 2 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+28 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/10/2017 8:40:28 AM Page 4 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ALKALINE PHOSPHATASE
Expected: S+28 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.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
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 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
Treatment Medications
mitomycin (MUTAMYCIN) injection 19.6 mg
19.6 mg (10 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-10 Minutes
IV side arm push. ** Vesicant **
fluorouracil (ADRUCIL) home infusion bag 7,840 mg
7,840 mg (4,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Four Day Infusion: Fluorouracil Dose = 1000 mg/m2/Day administered as a single continuous infusion IV over 96 hours.
(Total dose = 4000 mg/m2 IV over 96 hours).
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Zztestonc,Jeff J [2507481]
8/10/2017 8:40:28 AM Page 5 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
Day 5 (Pump Disconnect), Cycle 2 –  Planned for 9/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anal Cancer (Adjuvant); THERAPY: mitomycin 10 mg/m2 IV Day 1, fluorouracil 1000 mg/m2/day administered
as a continuous infusion IV over 96 hours on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per
home infusion); CYCLE LENGTH: 28 days; COURSE: 2 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 96-hour home 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]
8/10/2017 8:40:28 AM Page 6 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org