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CSC GI Fluorouracil(28D:1,15) Leucovorin(28D:1,15) Irinotecan(28D:1,15) VER 8-15-17 (HL 422)

CSC GI Fluorouracil(28D:1,15) Leucovorin(28D:1,15) Irinotecan(28D:1,15) VER 8-15-17 (HL 422) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI FLUOROURACIL(28D:1,15)/LEUCOVORIN(28D:1,15)/IRINOTECAN(28D:1,15) 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: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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
UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Take Home Medications
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 1 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-24 tab, R-5,
1 X DAILY starting S, Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
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 9/4/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/8/2017
Treatment Plan Information
Reference Information (1)
COLON AND RECTAL CANCER: Andre, et al. Eur J Cancer 1999;35:1343-7.
Reference Information (2)
COLON AND RECTAL CANCER: Tournigand, et al. J Clin Oncol 2004;23:229-37.
Reference Information (3)
GASTRIC/ESOPHAGEAL CANCER: Guimbaud R, et al. J Clin Oncol 2014;32(31):3520-26.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 2 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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
irinotecan CONVENTIONAL (CAMPTOSAR) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 3 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/fluorouracil/leucovorin
for 150 minutes.
DAY 17 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 to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, CEA;
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/fluorouracil/leucovorin for 150 minutes.
Day 3 (Pump Disconnect), Cycle 1 –  Planned for 8/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 –  Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 4 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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
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.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion 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 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
irinotecan CONVENTIONAL (CAMPTOSAR) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 5 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90
minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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.
Day 17 (Pump Disconnect), Cycle 1 –  Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 6 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  9/5/2017 through 10/2/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
Treatment Conditions
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 7 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion 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 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
irinotecan CONVENTIONAL (CAMPTOSAR) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 8 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/fluorouracil/leucovorin
for 150 minutes.
DAY 17 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 to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, CEA;
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/fluorouracil/leucovorin for 150 minutes.
Day 3 (Pump Disconnect), Cycle 2 –  Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 9 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 –  Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
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.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion 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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 10 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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
irinotecan CONVENTIONAL (CAMPTOSAR) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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.
Day 17 (Pump Disconnect), Cycle 2 –  Planned for 9/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 11 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  10/3/2017 through 10/30/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 12 of 33
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
UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
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.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion 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 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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 13 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

irinotecan CONVENTIONAL (CAMPTOSAR) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 90 minutes.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/fluorouracil/leucovorin
for 150 minutes.
DAY 17 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 to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, CEA;
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/fluorouracil/leucovorin for 150 minutes.
Day 3 (Pump Disconnect), Cycle 3 –  Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 14 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 –  Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
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.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion 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
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 15 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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
irinotecan CONVENTIONAL (CAMPTOSAR) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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.
Day 17 (Pump Disconnect), Cycle 3 –  Planned for 10/19/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 16 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  10/31/2017 through 11/27/2017 (28 days), Planned
Day 1, Cycle 4 –  Planned for 10/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 17 of 33
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
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
UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
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.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion 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 2:16:22 PM Page 18 of 33
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 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
irinotecan CONVENTIONAL (CAMPTOSAR) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/fluorouracil/leucovorin
for 150 minutes.
DAY 17 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 to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, CEA;
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/fluorouracil/leucovorin for 150 minutes.
Day 3 (Pump Disconnect), Cycle 4 –  Planned for 11/2/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 19 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY:
irinotecan 180 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400
mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous
infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home infusion) on
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 –  Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 20 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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
Page Or Call ___________
Notify Home infusion 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 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
irinotecan CONVENTIONAL (CAMPTOSAR) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 21 of 33
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.
Day 17 (Pump Disconnect), Cycle 4 –  Planned for 11/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  11/28/2017 through 12/25/2017 (28 days), Planned
Day 1, Cycle 5 –  Planned for 11/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 22 of 33
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+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
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.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Monitoring Parameters (1)
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 23 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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 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
irinotecan CONVENTIONAL (CAMPTOSAR) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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 3 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 24 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/fluorouracil/leucovorin
for 150 minutes.
DAY 17 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 to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, CEA;
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/fluorouracil/leucovorin for 150 minutes.
Day 3 (Pump Disconnect), Cycle 5 –  Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 –  Planned for 12/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 25 of 33
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+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion 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 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
irinotecan CONVENTIONAL (CAMPTOSAR) 352.8 mg in dextrose 5 % 250 mL bag
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 26 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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.
Day 17 (Pump Disconnect), Cycle 5 –  Planned for 12/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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 46-hour fluorouracil infusion.
Follow-Up
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 27 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  12/26/2017 through 1/22/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 12/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
UGT1A1 Lab Note
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 28 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior to the start of
irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
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.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion 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 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
irinotecan CONVENTIONAL (CAMPTOSAR) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 29 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/fluorouracil/leucovorin
for 150 minutes.
DAY 17 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 to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, CEA;
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan/fluorouracil/leucovorin for 150 minutes.
Day 3 (Pump Disconnect), Cycle 6 –  Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 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 46-hour fluorouracil infusion.
Follow-Up
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 30 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 –  Planned for 1/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
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.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion 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 2:16:22 PM Page 31 of 33
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 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
irinotecan CONVENTIONAL (CAMPTOSAR) 352.8 mg in dextrose 5 % 250 mL bag
352.8 mg (180 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 90 minutes.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Leucovorin may be administered (via separate infusion lines), concurrently with irinotecan over 90 minutes.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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.
Day 17 (Pump Disconnect), Cycle 6 –  Planned for 1/11/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced)/Gastric/Esophageal Cancer (Advanced); THERAPY: irinotecan 180 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours. (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
8/8/2017 2:16:22 PM Page 32 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-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 2:16:22 PM Page 33 of 33
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org