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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 Fluorouracil(28D:1,15) Leucovorin(28D:1,15) Oxaliplatin(28D:1,15) Panitumumab(28D:1,15) VER 8-15-17 (HL 5789)

CSC GI Fluorouracil(28D:1,15) Leucovorin(28D:1,15) Oxaliplatin(28D:1,15) Panitumumab(28D:1,15) VER 8-15-17 (HL 5789) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI FLUOROURACIL(28D:1,15)/LEUCOVORIN(28D:1,15)/OXALIPLATIN(28D:1,15)/PANITUMUMAB(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); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
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
CALCIUM
Expected: S Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S Approximate, Expires: S+365, Routine
PHOSPHATE
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
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S Approximate, Expires: S+365, Routine
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 1 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Page Or Call ___________
Notify Home infusion provider.
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
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
doxycycline hyclate 100 MG tab
Take 1 tab by mouth 2 times daily at mealtime., 100 mg, Disp-60 tab, R-5, 2 X DAILY (AT MEALTIME) starting S, Local
Printer
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 (ADVANCED): Douillard JY, et al. Ann Oncol 2014;25(7):1346-55.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 2 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Patient Instructions(1)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Patient Instructions(2)
Educate patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 3 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
panitumumab 486 mg in sodium chloride 0.9 % 100 mL bag
486 mg (6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. For doses greater than 1000 mg, dilute in 250 mL and administer over 90 minutes.
Hypersensitivity reaction to panitumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT: panitumumab, oxaliplatin, leucovorin, fluorouracil for
240 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Magnesium, Phosphate, AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: panitumumab, oxaliplatin, leucovorin, fluorouracil for 240 minutes.
Day 3 (Pump Disconnect), Cycle 1 –  Planned for 8/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 4 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 –  Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 5 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated
in a location to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Patient Instructions(1)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Patient Instructions(2)
Educate patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 6 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Treatment Medications
panitumumab 486 mg in sodium chloride 0.9 % 100 mL bag
486 mg (6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. For doses greater than 1000 mg, dilute in 250 mL and administer over 90 minutes.
Hypersensitivity reaction to panitumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 1 –  Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 7 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
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); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
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
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+14 Approximate, Expires: S+365, Routine
PHOSPHATE
Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 8 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Patient Instructions(1)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Patient Instructions(2)
Educate patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
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
dextrose 5 % infusion
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 9 of 40
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.
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
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
panitumumab 486 mg in sodium chloride 0.9 % 100 mL bag
486 mg (6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. For doses greater than 1000 mg, dilute in 250 mL and administer over 90 minutes.
Hypersensitivity reaction to panitumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 10 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT: panitumumab, oxaliplatin, leucovorin, fluorouracil for
240 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Magnesium, Phosphate, AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: panitumumab, oxaliplatin, leucovorin, fluorouracil for 240 minutes.
Day 3 (Pump Disconnect), Cycle 2 –  Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 –  Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 11 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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 WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Patient Instructions(1)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Patient Instructions(2)
Educate patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
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
dextrose 5 % 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]
8/8/2017 3:11:52 PM Page 12 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
panitumumab 486 mg in sodium chloride 0.9 % 100 mL bag
486 mg (6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. For doses greater than 1000 mg, dilute in 250 mL and administer over 90 minutes.
Hypersensitivity reaction to panitumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
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 3:11:52 PM Page 13 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Day 17 (Pump Disconnect), Cycle 2 –  Planned for 9/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 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); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 14 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
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
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+14 Approximate, Expires: S+365, Routine
PHOSPHATE
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
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 15 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure
(use sunscreen, wear hats) and to contact provider if rash or other skin reaction occurs.
Patient Instructions(1)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Patient Instructions(2)
Educate patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
panitumumab 486 mg in sodium chloride 0.9 % 100 mL bag
486 mg (6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. For doses greater than 1000 mg, dilute in 250 mL and administer over 90 minutes.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 16 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Hypersensitivity reaction to panitumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT: panitumumab, oxaliplatin, leucovorin, fluorouracil for
240 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Magnesium, Phosphate, AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: panitumumab, oxaliplatin, leucovorin, fluorouracil for 240 minutes.
Day 3 (Pump Disconnect), Cycle 3 –  Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 17 of 40
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.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 –  Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 18 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Patient Instructions(1)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Patient Instructions(2)
Educate patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
panitumumab 486 mg in sodium chloride 0.9 % 100 mL bag
486 mg (6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. For doses greater than 1000 mg, dilute in 250 mL and administer over 90 minutes.
Hypersensitivity reaction to panitumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 19 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 3 –  Planned for 10/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 20 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 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); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
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
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+14 Approximate, Expires: S+365, Routine
PHOSPHATE
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
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 21 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Patient Instructions(1)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Patient Instructions(2)
Educate patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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]
8/8/2017 3:11:52 PM Page 22 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
panitumumab 486 mg in sodium chloride 0.9 % 100 mL bag
486 mg (6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. For doses greater than 1000 mg, dilute in 250 mL and administer over 90 minutes.
Hypersensitivity reaction to panitumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT: panitumumab, oxaliplatin, leucovorin, fluorouracil for
240 minutes.
DAY 17 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 23 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

PROCEDURE: Pump disconnect for 15 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Magnesium, Phosphate, AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: panitumumab, oxaliplatin, leucovorin, fluorouracil for 240 minutes.
Day 3 (Pump Disconnect), Cycle 4 –  Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 –  Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 24 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Patient Instructions(1)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Patient Instructions(2)
Educate patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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 3:11:52 PM Page 25 of 40
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
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
panitumumab 486 mg in sodium chloride 0.9 % 100 mL bag
486 mg (6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. For doses greater than 1000 mg, dilute in 250 mL and administer over 90 minutes.
Hypersensitivity reaction to panitumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 4 –  Planned for 11/16/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 26 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  11/28/2017 through 12/25/2017 (28 days), Planned
Day 1, Cycle 5 –  Planned for 11/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 27 of 40
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
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
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+14 Approximate, Expires: S+365, Routine
PHOSPHATE
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
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Patient Instructions(1)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 28 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Patient Instructions(2)
Educate patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
panitumumab 486 mg in sodium chloride 0.9 % 100 mL bag
486 mg (6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. For doses greater than 1000 mg, dilute in 250 mL and administer over 90 minutes.
Hypersensitivity reaction to panitumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 29 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT: panitumumab, oxaliplatin, leucovorin, fluorouracil for
240 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Magnesium, Phosphate, AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: panitumumab, oxaliplatin, leucovorin, fluorouracil for 240 minutes.
Day 3 (Pump Disconnect), Cycle 5 –  Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 30 of 40
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.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 –  Planned for 12/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Patient Instructions(1)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 31 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Patient Instructions(2)
Educate patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
panitumumab 486 mg in sodium chloride 0.9 % 100 mL bag
486 mg (6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. For doses greater than 1000 mg, dilute in 250 mL and administer over 90 minutes.
Hypersensitivity reaction to panitumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 32 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 5 –  Planned for 12/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 33 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
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
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+14 Approximate, Expires: S+365, Routine
PHOSPHATE
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
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 34 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

CARCINOEMBRYONIC ANTIGEN
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Patient Instructions(1)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Patient Instructions(2)
Educate patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
Give 30 minutes prior to chemotherapy.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 35 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
panitumumab 486 mg in sodium chloride 0.9 % 100 mL bag
486 mg (6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. For doses greater than 1000 mg, dilute in 250 mL and administer over 90 minutes.
Hypersensitivity reaction to panitumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT: panitumumab, oxaliplatin, leucovorin, fluorouracil for
240 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 29 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 36 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Magnesium, Phosphate, AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: panitumumab, oxaliplatin, leucovorin, fluorouracil for 240 minutes.
Day 3 (Pump Disconnect), Cycle 6 –  Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 –  Planned for 1/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 37 of 40
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 with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Patient Instructions(1)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Patient Instructions(2)
Educate patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 38 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
panitumumab 486 mg in sodium chloride 0.9 % 100 mL bag
486 mg (6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. For doses greater than 1000 mg, dilute in 250 mL and administer over 90 minutes.
Hypersensitivity reaction to panitumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 6 –  Planned for 1/11/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 6 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2
IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by
fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46
hours per cycle per home infusion) Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease
progression.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 39 of 40
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:11:52 PM Page 40 of 40
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org