/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-96791-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 Cisplatin(21D:1)/Fluorouracil(21D:1-4) VER 11-10-17 (HL 982)

CSC HEAD/NECK Cisplatin(21D:1)/Fluorouracil(21D:1-4) VER 11-10-17 (HL 982) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Head and Neck


CSC HEAD/NECK 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: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 days;
COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+396, Routine
CALCIUM
Expected: S Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Actions
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 9:56:56 AM Page 1 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following chemotherapy., 80 mg, Disp-2 cap, R-5, 1 X DAILY
starting S
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy., 8 mg, Disp-24 tab, R-5, 1 X DAILY
starting S
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: Colevas AD, et al. J Clin Oncol 2006;24:2644-52.
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 days;
COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
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...
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
Zztestonc,PedsBeiber [2668824]
11/13/2017 9:56:56 AM Page 2 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Page Or Call ___________
Notify Home infusion provider.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 500-1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Administered over 1 to 2 hours BEFORE CISplatin.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
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
Treatment 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
For 60 to 90 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,000 mg/m2 (Treatment Plan)
4,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Four Day Infusion: Fluorouracil Dose = 1000 mg/m2/Day administered as a single continuous infusion IV over 96 hours.
(Total dose = 4000 mg/m2 IV over 96 hours).
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
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 9:56:56 AM Page 3 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and fluorouracil for 150 minutes.
Day 5 (Pump Disconnect), Cycle 1 –  Planned for 11/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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.
Lab Only - Day 10, Cycle 1 –  Planned for 11/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 9:56:56 AM Page 4 of 22
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+9 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 Approximate, Expires: S+365, Routine
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: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
ALBUMIN
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 9:56:56 AM Page 5 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 500-1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Administered over 1 to 2 hours BEFORE CISplatin.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
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 9:56:56 AM Page 6 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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
Treatment 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
For 60 to 90 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,000 mg/m2 (Treatment Plan)
4,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Four Day Infusion: Fluorouracil Dose = 1000 mg/m2/Day administered as a single continuous infusion IV over 96 hours.
(Total dose = 4000 mg/m2 IV over 96 hours).
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and fluorouracil for 150 minutes.
Day 5 (Pump Disconnect), Cycle 2 –  Planned for 12/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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.
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 9:56:56 AM Page 7 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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.
Lab Only - Day 10, Cycle 2 –  Planned for 12/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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+9 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 Approximate, Expires: S+365, Routine
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: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 days;
COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
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
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 9:56:56 AM Page 8 of 22
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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 9:56:56 AM Page 9 of 22
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 500-1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Administered over 1 to 2 hours BEFORE CISplatin.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
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
Treatment 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
For 60 to 90 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,000 mg/m2 (Treatment Plan)
4,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Four Day Infusion: Fluorouracil Dose = 1000 mg/m2/Day administered as a single continuous infusion IV over 96 hours.
(Total dose = 4000 mg/m2 IV over 96 hours).
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and fluorouracil for 150 minutes.
Day 5 (Pump Disconnect), Cycle 3 –  Planned for 12/29/2017
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 9:56:56 AM Page 10 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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.
Lab Only - Day 10, Cycle 3 –  Planned for 1/3/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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+9 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
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 9:56:56 AM Page 11 of 22
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.
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: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
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 9:56:56 AM Page 12 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 500-1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Administered over 1 to 2 hours BEFORE CISplatin.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
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
Treatment 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
For 60 to 90 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
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 9:56:56 AM Page 13 of 22
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
Four Day Infusion: Fluorouracil Dose = 1000 mg/m2/Day administered as a single continuous infusion IV over 96 hours.
(Total dose = 4000 mg/m2 IV over 96 hours).
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and fluorouracil for 150 minutes.
Day 5 (Pump Disconnect), Cycle 4 –  Planned for 1/19/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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.
Lab Only - Day 10, Cycle 4 –  Planned for 1/24/2018
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 9:56:56 AM Page 14 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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+9 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 Approximate, Expires: S+365, Routine
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: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
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 9:56:56 AM Page 15 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
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 9:56:56 AM Page 16 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

at 500-1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Administered over 1 to 2 hours BEFORE CISplatin.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
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
Treatment 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
For 60 to 90 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,000 mg/m2 (Treatment Plan)
4,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Four Day Infusion: Fluorouracil Dose = 1000 mg/m2/Day administered as a single continuous infusion IV over 96 hours.
(Total dose = 4000 mg/m2 IV over 96 hours).
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and fluorouracil for 150 minutes.
Day 5 (Pump Disconnect), Cycle 5 –  Planned for 2/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 days;
COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
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 9:56:56 AM Page 17 of 22
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.
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.
Lab Only - Day 10, Cycle 5 –  Planned for 2/14/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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+9 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
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 9:56:56 AM Page 18 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than ULN.
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
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 9:56:56 AM Page 19 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Page Or Call ___________
Notify Home infusion provider.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 500-1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Administered over 1 to 2 hours BEFORE CISplatin.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
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
Treatment 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
For 60 to 90 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,000 mg/m2 (Treatment Plan)
4,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Four Day Infusion: Fluorouracil Dose = 1000 mg/m2/Day administered as a single continuous infusion IV over 96 hours.
(Total dose = 4000 mg/m2 IV over 96 hours).
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 5 FOLLOW-UP
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 9:56:56 AM Page 20 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

PROCEDURE: Pump disconnect for 15 minutes
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and fluorouracil for 150 minutes.
Day 5 (Pump Disconnect), Cycle 6 –  Planned for 3/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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.
Lab Only - Day 10, Cycle 6 –  Planned for 3/7/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (Adjuvant/Advanced); THERAPY:
CISplatin 100 mg/m2 IV on Day 1, fluorouracil 1,000 mg/m2/day administered as a continuous infusion IV over 96 hours
on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 21 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.
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 9:56:56 AM Page 21 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+9 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Actions
Actions
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 9:56:56 AM Page 22 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org