/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/head-and-neck/,

/clinical/cckm-tools/content/beacon-protocols/head-and-neck/name-96787-en.cckm

201711317

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Head and Neck

CSC HEAD/NECK Cetuximab(21D:1,8,15) Cisplatin(21D:1) Fluorouracil(21D:1-4) VER 11-10-17 (HL 1987)

CSC HEAD/NECK Cetuximab(21D:1,8,15) Cisplatin(21D:1) Fluorouracil(21D:1-4) VER 11-10-17 (HL 1987) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Head and Neck


CSC HEAD/NECK CETUXIMAB(21D:1,8,15)/CISPLATIN(21D:1)/FLUOROURACIL(21D:1-4) VER:
11/10/17 –  Properties
Pre-Cycle –  11/6/2017 through 11/12/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 11/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S Approximate, Expires: S+365, Normal, Routine
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take on Day 2 and 3., 80 mg, Disp-2 cap, R-5, 1 X DAILY starting S
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...
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 1 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 2, 3 and 4., 8 mg, Disp-24 tab, R-1, 1 X DAILY
starting S
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed., 8 mg, Disp-20 tab, R-5, EVERY 8 HOURS PRN starting S, Local Printer
Cycle 1 –  11/13/2017 through 12/3/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 11/13/2017
Treatment Plan Information
Reference Information (1)
HEAD/NECK CANCER: Vermorken J, et al. N Engl J Med. 2008;359(11):1116-27.
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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, Potassium, Magnesium
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL, Platelets less than or equal to
100K/µL, Potassium less than 3.5 mmol/L or greater than 4.8 mmol/L, Creatinine greater than 1.3 mg/dL or Magnesium
less than 1.7 mg/dL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
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...
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 2 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Measure Intake And Output
EVERY 4 HOURS Starting when released for 1 day
Measure IV intake and urine output.
Patient Instructions(1)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 500-999 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
Infuse 1000 mL over 1-2 hours prior to CISplatin.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to cetuximab.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 15 Minutes
Give 30 minutes prior to cetuximab.
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Give prior to CISplatin.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to CISplatin.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Give prior to CISplatin.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 3 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 400 mg/m2 (Treatment Plan)
400 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 120 Minutes
Administer over 120 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1 infusion.
See Emergency Medications.
CISplatin (PLATINOL) 100 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
100 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 120 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,000 mg/m2 (Treatment Plan)
4,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 96 hours per home infusion company. Total dose = 4000 mg/m2 over 96 hours.
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT for
cetuximab for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT for
cetuximab for 90 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
done locally), Sodium, Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: cetuximab and CISplatin for 180 minutes
Day 5 (Pump Disconnect), Cycle 1 –  Planned for 11/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; CYCLE
LENGTH: 28 days; COURSE: 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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 4 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@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 96-hour home infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 –  Planned for 11/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 5 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
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 11/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 6 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 7 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  12/4/2017 through 12/24/2017 (21 days), Planned
Day 1, Cycle 2 –  Planned for 12/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 8 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Potassium, Magnesium
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL, Platelets less than or equal to
100K/µL, Potassium less than 3.5 mmol/L or greater than 4.8 mmol/L, Creatinine greater than 1.3 mg/dL or Magnesium
less than 1.7 mg/dL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Measure Intake And Output
EVERY 4 HOURS Starting when released for 1 day
Measure IV intake and urine output.
Patient Instructions(1)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 500-999 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
Infuse 1000 mL over 1-2 hours prior to CISplatin.
Pre-Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 9 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for
adults or 15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1 infusion.
CISplatin (PLATINOL) 100 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
100 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 120 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,000 mg/m2 (Treatment Plan)
4,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 96 hours per home infusion company. Total dose = 4000 mg/m2 over 96 hours.
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT for
cetuximab for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT for
cetuximab for 90 minutes.
DAY 22 FOLLOW-UP
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 10 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
done locally), Sodium, Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: cetuximab and CISplatin for 180 minutes
Day 5 (Pump Disconnect), Cycle 2 –  Planned for 12/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; CYCLE
LENGTH: 28 days; COURSE: 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 96-hour home infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 2 –  Planned for 12/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 11 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 12 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute.
Hypersensitivity reaction to cetuximab can occur.  For first and second dose, patient should be treated
in a location to optimize emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60
MINUTES FOLLOWING THE COMPLETION OF THE FIRST DOSE. See Emergency Medications.
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 12/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 13 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  12/25/2017 through 1/14/2018 (21 days), Planned
Day 1, Cycle 3 –  Planned for 12/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 14 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Potassium, Magnesium
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL, Platelets less than or equal to
100K/µL, Potassium less than 3.5 mmol/L or greater than 4.8 mmol/L, Creatinine greater than 1.3 mg/dL or Magnesium
less than 1.7 mg/dL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Measure Intake And Output
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 15 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

EVERY 4 HOURS Starting when released for 1 day
Measure IV intake and urine output.
Patient Instructions(1)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 500-999 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
Infuse 1000 mL over 1-2 hours prior to CISplatin.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 16 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1 infusion.
CISplatin (PLATINOL) 100 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
100 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 120 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,000 mg/m2 (Treatment Plan)
4,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 96 hours per home infusion company. Total dose = 4000 mg/m2 over 96 hours.
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT for
cetuximab for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT for
cetuximab for 90 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
done locally), Sodium, Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: cetuximab and CISplatin for 180 minutes
Day 5 (Pump Disconnect), Cycle 3 –  Planned for 12/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; CYCLE
LENGTH: 28 days; COURSE: 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 96-hour home infusion.
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 17 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 3 –  Planned for 1/1/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
To establish line and for flushing
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 18 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
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 1/8/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 19 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 20 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  1/15/2018 through 2/4/2018 (21 days), Planned
Day 1, Cycle 4 –  Planned for 1/15/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 21 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Expected: S+7 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Potassium, Magnesium
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL, Platelets less than or equal to
100K/µL, Potassium less than 3.5 mmol/L or greater than 4.8 mmol/L, Creatinine greater than 1.3 mg/dL or Magnesium
less than 1.7 mg/dL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Measure Intake And Output
EVERY 4 HOURS Starting when released for 1 day
Measure IV intake and urine output.
Patient Instructions(1)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 500-999 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
Infuse 1000 mL over 1-2 hours prior to CISplatin.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 22 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1 infusion.
CISplatin (PLATINOL) 100 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
100 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 120 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,000 mg/m2 (Treatment Plan)
4,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 96 hours per home infusion company. Total dose = 4000 mg/m2 over 96 hours.
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT for
cetuximab for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT for
cetuximab for 90 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
done locally), Sodium, Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: cetuximab and CISplatin for 180 minutes
Day 5 (Pump Disconnect), Cycle 4 –  Planned for 1/19/2018
Treatment Plan Information
Treatment Plan Summary
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 23 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; CYCLE
LENGTH: 28 days; COURSE: 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 96-hour home infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 4 –  Planned for 1/22/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 24 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 25 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 –  Planned for 1/29/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 26 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  2/5/2018 through 2/25/2018 (21 days), Planned
Day 1, Cycle 5 –  Planned for 2/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 27 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Potassium, Magnesium
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL, Platelets less than or equal to
100K/µL, Potassium less than 3.5 mmol/L or greater than 4.8 mmol/L, Creatinine greater than 1.3 mg/dL or Magnesium
less than 1.7 mg/dL.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Measure Intake And Output
EVERY 4 HOURS Starting when released for 1 day
Measure IV intake and urine output.
Patient Instructions(1)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 28 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 500-999 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
Infuse 1000 mL over 1-2 hours prior to CISplatin.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1 infusion.
CISplatin (PLATINOL) 100 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
100 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 120 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,000 mg/m2 (Treatment Plan)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 29 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

4,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 96 hours per home infusion company. Total dose = 4000 mg/m2 over 96 hours.
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT for
cetuximab for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT for
cetuximab for 90 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
done locally), Sodium, Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: cetuximab and CISplatin for 180 minutes
Day 5 (Pump Disconnect), Cycle 5 –  Planned for 2/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; CYCLE
LENGTH: 28 days; COURSE: 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 96-hour home infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 5 –  Planned for 2/12/2018
Treatment Plan Information
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 30 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle
1 Day 1 then cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through
6; CISplatin 100 mg/m2 IV Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4
(total dose = 4000 mg/m2 over 96 hours); CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by
THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 31 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
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 2/19/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 32 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 33 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Cycle 6 –  2/26/2018 through 3/18/2018 (21 days), Planned
Day 1, Cycle 6 –  Planned for 2/26/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Potassium, Magnesium
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL, Platelets less than or equal to
100K/µL, Potassium less than 3.5 mmol/L or greater than 4.8 mmol/L, Creatinine greater than 1.3 mg/dL or Magnesium
less than 1.7 mg/dL.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 34 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify home infusion provider for fluorouracil administration.
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Measure Intake And Output
EVERY 4 HOURS Starting when released for 1 day
Measure IV intake and urine output.
Patient Instructions(1)
Fluorouracil: Educate patient about mucositis and hand-foot syndrome.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 500-999 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
Infuse 1000 mL over 1-2 hours prior to CISplatin.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 35 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1 infusion.
CISplatin (PLATINOL) 100 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
100 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 120 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,000 mg/m2 (Treatment Plan)
4,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 96 hours per home infusion company. Total dose = 4000 mg/m2 over 96 hours.
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT for
cetuximab for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT for
cetuximab for 90 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
done locally), Sodium, Potassium, Chloride, Carbon Dioxide, AST, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT:
cetuximab for 90 minutes
Day 5 (Pump Disconnect), Cycle 6 –  Planned for 3/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 36 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 6 –  Planned for 3/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 37 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. Patient must remain in treatment area for 60 minutes
following completion of Cycle 1 Day 1 infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
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 3/12/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 38 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, CONTINUOUS, For 1 day Starting when released until S at 2359
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 39 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 –  3/19/2018 through 4/15/2018 (28 days), Planned
Day 1, Cycle 7 –  Planned for 3/19/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 40 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Potassium, Magnesium
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL, Platelets less than or equal to
100K/µL, Potassium less than 3.5 mmol/L or greater than 4.8 mmol/L or Magnesium less than 1.7 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 41 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
Take Home Medications
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: cetuximab for
90 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: cetuximab for
90 minutes
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: cetuximab for
90 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Sodium,
Potassium, Chloride, Carbon Dioxide, AST, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: cetuximab for 90
minutes
Day 8, Cycle 7 –  Planned for 3/26/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 42 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 Minutes
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 43 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 7 –  Planned for 4/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 44 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 45 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 7 –  Planned for 4/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Advanced); THERAPY: cetuximab 400 mg/m2 IV (loading dose) Cycle 1 Day 1 then
cetuximab 250 mg/m2 IV Day 8 and 15 of Cycle 1 and Day 1, 8 and 15 for Cycle 2 through 6; CISplatin 100 mg/m2 IV
Day 1; fluorouracil 1000 mg/m2 IV continuous infusion Day 1 through 4 (total dose = 4000 mg/m2 over 96 hours);
CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: cetuximab 250 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must remain in treatment area for 60 minutes following completion of Cycle 1 Day 1
infusion.
Vital Signs
SEE COMMENTS Starting when released until S for 1 day
Cetuximab: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion. For first and second doses, RN will remain with the patient during the first 15 minutes of drug administration.
Flush Venous Access Device per Guidelines
Order details
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 46 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 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 15 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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 60 Minutes
Administer over 60 minutes with 0.2 or 0.22 micron filter. Do not dilute. Maximum rate 5 mL/minute. Hypersensitivity
reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF
THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:31:43 AM Page 47 of 47
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org