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201708223

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UWHC,UWMF,

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

CSC GI Irinotecan(28D:1,15) VER 8-15-17 (HL 373)

CSC GI Irinotecan(28D:1,15) VER 8-15-17 (HL 373) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI 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) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
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.
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
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
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 1 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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: Cunningham, D., et al. Lancet 1998;352:1413-8.
Reference Information (2)
GASTRIC/ESOPHAGEAL CANCER (Advanced): Thuss-Patience P, et al. European Journal of Cancer 2011;47:2306-14.
Reference Information (3)
GASTRIC/ESOPHAGEAL CANCER (Advanced): Hironaka S, et al. J Clin Oncol 2013;31(35):4438-44.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
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
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 2 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 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) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes. If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is
greater than 750 mg then use Dextrose 5% in water 500 mL.
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 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  irinotecan  for 90 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; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 90 minutes.
Day 15, Cycle 1 –  Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
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]
8/8/2017 1:32:32 PM Page 3 of 21
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+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 1,500/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes. If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is
greater than 750 mg then use Dextrose 5% in water 500 mL.
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
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 4 of 21
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 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) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
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
Treatment Conditions
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 5 of 21
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 1,500/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes. If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is
greater than 750 mg then use Dextrose 5% in water 500 mL.
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 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  irinotecan  for 90 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; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 90 minutes.
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 6 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Day 15, Cycle 2 –  Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
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
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
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 7 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes. If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is
greater than 750 mg then use Dextrose 5% in water 500 mL.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  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) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 8 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
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 1,500/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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) in dextrose 5 % 250 mL bag
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 9 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes. If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is
greater than 750 mg then use Dextrose 5% in water 500 mL.
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 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  irinotecan  for 90 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; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 90 minutes.
Day 15, Cycle 3 –  Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
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
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
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 10 of 21
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.
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) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes. If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is
greater than 750 mg then use Dextrose 5% in water 500 mL.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  10/31/2017 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) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 11 of 21
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
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
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 1,500/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 12 of 21
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 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) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes. If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is
greater than 750 mg then use Dextrose 5% in water 500 mL.
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 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  irinotecan  for 90 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; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 90 minutes.
Day 15, Cycle 4 –  Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
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 1:32:32 PM Page 13 of 21
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
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
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) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes. If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is
greater than 750 mg then use Dextrose 5% in water 500 mL.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 14 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 15 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes. If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is
greater than 750 mg then use Dextrose 5% in water 500 mL.
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 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  irinotecan  for 90 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; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 90 minutes.
Day 15, Cycle 5 –  Planned for 12/12/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 16 of 21
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) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
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
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
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 17 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes. If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is
greater than 750 mg then use Dextrose 5% in water 500 mL.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  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) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
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 1:32:32 PM Page 18 of 21
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
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 1,500/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes. If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is
greater than 750 mg then use Dextrose 5% in water 500 mL.
Conditional Orders
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 19 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT:  irinotecan  for 90 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; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 90 minutes.
Day 15, Cycle 6 –  Planned for 1/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced) without prior pelvic radiotherapy; Gastric/Esophageal Cancer (Advanced);
THERAPY: irinotecan 150 mg/m2 or 180 mg/m2 IV Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression; NOTE: for advanced gastric/esophageal dose is 150 mg/m2 IV; NOTE: for colon and rectal cancer dose is
180 mg/m2 IV.
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
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 20 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 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) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes. If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is
greater than 750 mg then use Dextrose 5% in water 500 mL.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 30 MINUTES PRN, 3 doses Starting when released, to prevent cholinergic syndrome,
Administer over 1 Minutes
May repeat 2 times (Total of 3 doses). Total allowed dose = 0.9 mg
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/8/2017 1:32:32 PM Page 21 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org