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UWHC,UWMF,

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CSC GI Fluorouracil(56D:1,8,15,22,29,36) Leucovorin(56D:1,8,15,22,29,36) VER 8-15-17 (HL 374)

CSC GI Fluorouracil(56D:1,8,15,22,29,36) Leucovorin(56D:1,8,15,22,29,36) VER 8-15-17 (HL 374) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI FLUOROURACIL(56D:1,8,15,22,29,36)/LEUCOVORIN(56D:1,8,15,22,29,36) 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: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
Cycle 1 –  8/10/2017 through 10/4/2017 (56 days), Planned
Day 1, Cycle 1 –  Planned for 8/10/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 1 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Reference Information (1)
COLON AND RECTAL CANCER: Haller, et al. J of Clin Oncol 1997;15:246-50.
Reference Information (2)
COLON AND RECTAL CANCER: Petrelli, et al. J of Clin Oncol 1989;7:1419-26.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 2 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 36 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 57 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for 150 minutes.
Day 8, Cycle 1 –  Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 3 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 4 of 28
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 1 –  Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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]
8/10/2017 9:08:25 AM Page 5 of 28
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 –  Planned for 8/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
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
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 6 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 1 –  Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 7 of 28
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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 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
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 8 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 36, Cycle 1 –  Planned for 9/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 9 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  10/5/2017 through 11/29/2017 (56 days), Planned
Day 1, Cycle 2 –  Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 10 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 11 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 36 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 57 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for 150 minutes.
Day 8, Cycle 2 –  Planned for 10/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
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
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 12 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 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
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 13 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 –  Planned for 10/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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]
8/10/2017 9:08:25 AM Page 14 of 28
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 2 –  Planned for 10/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
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.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 15 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 2 –  Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 16 of 28
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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 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
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 17 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 36, Cycle 2 –  Planned for 11/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 18 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  11/30/2017 through 1/24/2018 (56 days), Planned
Day 1, Cycle 3 –  Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 19 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 20 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 36 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for
150 minutes.
DAY 57 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:  fluorouracil and leucovorin for 150 minutes.
Day 8, Cycle 3 –  Planned for 12/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
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
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 21 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 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
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 22 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 12/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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]
8/10/2017 9:08:25 AM Page 23 of 28
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 3 –  Planned for 12/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
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.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 24 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 3 –  Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 25 of 28
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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 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
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 26 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 36, Cycle 3 –  Planned for 1/4/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Adjuvant/Advanced); THERAPY: leucovorin 500 mg/m2 IV, Day 1, 8, 15, 22, 29, and
36, fluorouracil 600 mg/m2 IV bolus Day 1, 8, 15, 22, 29 and 36; CYCLE LENGTH: 56 days; COURSE: 3 cycles (total 6
months of therapy for adjuvant).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
Cryotherapy: patients should hold ice or ice-cold water in their mouths for five minutes prior to infusion, during
infusion, and for 30 minutes after completion of fluorouracil infusion.
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
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Zztestonc,Jeff J [2507481]
8/10/2017 9:08:25 AM Page 27 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
leucovorin 980 mg in dextrose 5 % 500 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour of
leucovorin infusion.
fluorouracil (ADRUCIL) injection 1,176 mg
1,176 mg (600 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.  One hour after the start of the leucovorin, interrupt and give fluorouracil IV bolus then complete second hour
of leucovorin 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 9:08:25 AM Page 28 of 28
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org