/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/gi/,

/clinical/cckm-tools/content/beacon-protocols/gi/name-96682-en.cckm

201708223

page

100

UWHC,UWMF,

Tools,

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

CSC GI Trifluridine-Tipiracil(28D:1-5,8-12) VER 8-15-17 (HL 5521)

CSC GI Trifluridine-Tipiracil(28D:1-5,8-12) VER 8-15-17 (HL 5521) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI TRIFLURIDINE/TIPIRACIL(28D:1-5,8-12) VER: 8-15-17 –  Properties
Pre-Cycle –  8/3/2017 through 8/9/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon Cancer (Advanced); THERAPY: trifluridine/tipiracil 35 mg/m2 by mouth twice daily Days 1 through 5 and
Days 8 through 12; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
CALCIUM
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
loperamide 2 MG cap
Take 2 tab by mouth with 1st loose stool followed by 1 tab every 2h or 2 tab every 4h until no diarrhea x12h. Max
dose=8 tab/day, Disp-30 cap, R-5, starting S, Local Printer
Counsel patient to purchase over the counter if not covered by insurance and provide instructions for use.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:48:52 AM Page 1 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Cycle 1 –  8/10/2017 through 9/6/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/10/2017
Treatment Plan Information
Reference Information (1)
COLON CANCER: Mayer RJ, et al. N Engl J Med 2015;372(20):1909-19.
Treatment Plan Summary
DISEASE: Colon Cancer (Advanced); THERAPY: trifluridine/tipiracil 35 mg/m2 by mouth twice daily Days 1 through 5 and
Days 8 through 12; CYCLE LENGTH: 28 days; COURSE: 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, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than or equal to 100K/µL or Total
Bilirubin greater than or equal to 1.5 mg/dL (unless solely due to medical diagnosis of Gilbert's syndrome) or AST
greater than or equal to 3 X ULN or ALT greater than or equal to 3 X ULN or Creatinine greater than or equal to 1.5
mg/dL.
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
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): trifluridine/tipiracil (dispensed
Day 1 of each Cycle).
Take Home Medications (delete all that do not apply)
trifluridine-tipiracil (LONSURF) 15-6.14 MG per tab
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Zztestonc,Jeff J [2507481]
8/10/2017 9:48:52 AM Page 2 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Take *** tabs by mouth twice daily within 1 hour after AM and PM meals on Days 1 thru 5 and 8 thru 12., R-0,
starting S
Starting dose = 35 mg/m2/dose (based on trifluridine component; maximum 80 mg/dose) by mouth twice daily Days 1
through 5 and 8 through 12. Round to nearest 5 mg increment.
trifluridine-tipiracil (LONSURF) 20-8.19 MG per tab
Take *** tabs by mouth twice daily within 1 hour after AM and PM meals on Days 1 thru 5 and 8 thru 12., R-0,
starting S
Starting dose = 35 mg/m2/dose (based on trifluridine component; maximum 80 mg/dose) by mouth twice daily Days 1
through 5 and 8 through 12. Round to nearest 5 mg increment.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose,
Creatinine, BUN, Calcium.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if to be done locally), ANC,
Electrolytes, Glucose, Creatinine, BUN, Calcium, Carcinoembryonic Antigen.
Day 15, Cycle 1 –  Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon Cancer (Advanced); THERAPY: trifluridine/tipiracil 35 mg/m2 by mouth twice daily Days 1 through 5 and
Days 8 through 12; CYCLE LENGTH: 28 days; COURSE: 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 WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Routine
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/10/2017 9:48:52 AM Page 3 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  9/7/2017 through 10/4/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon Cancer (Advanced); THERAPY: trifluridine/tipiracil 35 mg/m2 by mouth twice daily Days 1 through 5 and
Days 8 through 12; CYCLE LENGTH: 28 days; COURSE: 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 WITHOUT DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 75K/µL.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:48:52 AM Page 4 of 12
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
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): trifluridine/tipiracil (dispensed
Day 1 of each Cycle).
Take Home Medications (delete all that do not apply)
trifluridine-tipiracil (LONSURF) 15-6.14 MG per tab
Take *** tabs by mouth twice daily within 1 hour after AM and PM meals on Days 1 thru 5 and 8 thru 12., R-0,
starting S
Starting dose = 35 mg/m2/dose (based on trifluridine component; maximum 80 mg/dose) by mouth twice daily Days 1
through 5 and 8 through 12. Round to nearest 5 mg increment.
trifluridine-tipiracil (LONSURF) 20-8.19 MG per tab
Take *** tabs by mouth twice daily within 1 hour after AM and PM meals on Days 1 thru 5 and 8 thru 12., R-0,
starting S
Starting dose = 35 mg/m2/dose (based on trifluridine component; maximum 80 mg/dose) by mouth twice daily Days 1
through 5 and 8 through 12. Round to nearest 5 mg increment.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, Creatinine, BUN, Calcium, Carcinoembryonic Antigen.
Cycle 3 –  10/5/2017 through 11/1/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon Cancer (Advanced); THERAPY: trifluridine/tipiracil 35 mg/m2 by mouth twice daily Days 1 through 5 and
Days 8 through 12; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/10/2017 9:48:52 AM Page 5 of 12
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 WITHOUT DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 75K/µL.
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
See Take Home Medication(s)
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Zztestonc,Jeff J [2507481]
8/10/2017 9:48:52 AM Page 6 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): trifluridine/tipiracil (dispensed
Day 1 of each Cycle).
Take Home Medications (delete all that do not apply)
trifluridine-tipiracil (LONSURF) 15-6.14 MG per tab
Take *** tabs by mouth twice daily within 1 hour after AM and PM meals on Days 1 thru 5 and 8 thru 12., R-0,
starting S
Starting dose = 35 mg/m2/dose (based on trifluridine component; maximum 80 mg/dose) by mouth twice daily Days 1
through 5 and 8 through 12. Round to nearest 5 mg increment.
trifluridine-tipiracil (LONSURF) 20-8.19 MG per tab
Take *** tabs by mouth twice daily within 1 hour after AM and PM meals on Days 1 thru 5 and 8 thru 12., R-0,
starting S
Starting dose = 35 mg/m2/dose (based on trifluridine component; maximum 80 mg/dose) by mouth twice daily Days 1
through 5 and 8 through 12. Round to nearest 5 mg increment.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, Creatinine, BUN, Calcium, Carcinoembryonic Antigen.
Cycle 4 –  11/2/2017 through 11/29/2017 (28 days), Planned
Day 1, Cycle 4 –  Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon Cancer (Advanced); THERAPY: trifluridine/tipiracil 35 mg/m2 by mouth twice daily Days 1 through 5 and
Days 8 through 12; CYCLE LENGTH: 28 days; COURSE: 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 WITHOUT DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/10/2017 9:48:52 AM Page 7 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 75K/µL.
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
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): trifluridine/tipiracil (dispensed
Day 1 of each Cycle).
Take Home Medications (delete all that do not apply)
trifluridine-tipiracil (LONSURF) 15-6.14 MG per tab
Take *** tabs by mouth twice daily within 1 hour after AM and PM meals on Days 1 thru 5 and 8 thru 12., R-0,
starting S
Starting dose = 35 mg/m2/dose (based on trifluridine component; maximum 80 mg/dose) by mouth twice daily Days 1
through 5 and 8 through 12. Round to nearest 5 mg increment.
trifluridine-tipiracil (LONSURF) 20-8.19 MG per tab
Take *** tabs by mouth twice daily within 1 hour after AM and PM meals on Days 1 thru 5 and 8 thru 12., R-0,
starting S
Starting dose = 35 mg/m2/dose (based on trifluridine component; maximum 80 mg/dose) by mouth twice daily Days 1
through 5 and 8 through 12. Round to nearest 5 mg increment.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/10/2017 9:48:52 AM Page 8 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, Creatinine, BUN, Calcium, Carcinoembryonic Antigen.
Cycle 5 –  11/30/2017 through 12/27/2017 (28 days), Planned
Day 1, Cycle 5 –  Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon Cancer (Advanced); THERAPY: trifluridine/tipiracil 35 mg/m2 by mouth twice daily Days 1 through 5 and
Days 8 through 12; CYCLE LENGTH: 28 days; COURSE: 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 WITHOUT DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 75K/µL.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:48:52 AM Page 9 of 12
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
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): trifluridine/tipiracil (dispensed
Day 1 of each Cycle).
Take Home Medications (delete all that do not apply)
trifluridine-tipiracil (LONSURF) 15-6.14 MG per tab
Take *** tabs by mouth twice daily within 1 hour after AM and PM meals on Days 1 thru 5 and 8 thru 12., R-0,
starting S
Starting dose = 35 mg/m2/dose (based on trifluridine component; maximum 80 mg/dose) by mouth twice daily Days 1
through 5 and 8 through 12. Round to nearest 5 mg increment.
trifluridine-tipiracil (LONSURF) 20-8.19 MG per tab
Take *** tabs by mouth twice daily within 1 hour after AM and PM meals on Days 1 thru 5 and 8 thru 12., R-0,
starting S
Starting dose = 35 mg/m2/dose (based on trifluridine component; maximum 80 mg/dose) by mouth twice daily Days 1
through 5 and 8 through 12. Round to nearest 5 mg increment.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, Creatinine, BUN, Calcium, Carcinoembryonic Antigen.
Cycle 6 –  12/28/2017 through 1/24/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon Cancer (Advanced); THERAPY: trifluridine/tipiracil 35 mg/m2 by mouth twice daily Days 1 through 5 and
Days 8 through 12; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/10/2017 9:48:52 AM Page 10 of 12
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 WITHOUT DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 75K/µL.
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
See Take Home Medication(s)
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Zztestonc,Jeff J [2507481]
8/10/2017 9:48:52 AM Page 11 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): trifluridine/tipiracil (dispensed
Day 1 of each Cycle).
Take Home Medications (delete all that do not apply)
trifluridine-tipiracil (LONSURF) 15-6.14 MG per tab
Take *** tabs by mouth twice daily within 1 hour after AM and PM meals on Days 1 thru 5 and 8 thru 12., R-0,
starting S
Starting dose = 35 mg/m2/dose (based on trifluridine component; maximum 80 mg/dose) by mouth twice daily Days 1
through 5 and 8 through 12. Round to nearest 5 mg increment.
trifluridine-tipiracil (LONSURF) 20-8.19 MG per tab
Take *** tabs by mouth twice daily within 1 hour after AM and PM meals on Days 1 thru 5 and 8 thru 12., R-0,
starting S
Starting dose = 35 mg/m2/dose (based on trifluridine component; maximum 80 mg/dose) by mouth twice daily Days 1
through 5 and 8 through 12. Round to nearest 5 mg increment.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, Creatinine, BUN, Calcium, Carcinoembryonic Antigen.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/10/2017 9:48:52 AM Page 12 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org