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/clinical/cckm-tools/content/beacon-protocols/head-and-neck/name-96795-en.cckm

201711317

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100

UWHC,UWMF,

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

CSC HEAD NECK Concurrent XRT Doxorubicin(42D:1,8,15,22,29,36) VER 11-10-17 (HL 4325)

CSC HEAD NECK Concurrent XRT Doxorubicin(42D:1,8,15,22,29,36) VER 11-10-17 (HL 4325) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Head and Neck


CSC HEAD/NECK CONCURRENT XRT DOXORUBICIN(42D:1,8,15,22,29,36) 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: Anaplastic Thyroid Cancer (Advanced); THERAPY: doxorubicin CONVENTIONAL 10 mg/m2 IV prior to
radiotherapy on Day 1, 8, 15, 22, 29, 36; CYCLE LENGTH: 42 days; COURSE: 1 cycle
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
ALT/SGPT
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
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
Cycle 1 –  11/13/2017 through 12/24/2017 (42 days), Planned
Day 1, Cycle 1 –  Planned for 11/13/2017
Treatment Plan Information
Reference Information (1)
HEAD/NECK CANCER: Kim J, et al. Cancer 1987;60:2372-75
Reference Information (2)
HEAD/NECK CANCER: Tennvall J, et al. Cancer 1994;74:1348-54
Treatment Plan Summary
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:40:06 AM Page 1 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

DISEASE: Anaplastic Thyroid Cancer (Advanced); THERAPY: doxorubicin CONVENTIONAL 10 mg/m2 IV prior to
radiotherapy on Day 1, 8, 15, 22, 29, 36; CYCLE LENGTH: 42 days; COURSE: 1 cycle
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin
greater than ULN
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.
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
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 10 mg/m2 (Treatment Plan)
10 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
IV side arm push 3-5 mL/minute into running IV.
Follow-Up
DAY 8 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, BUN, Creatinine, Total Bilirubin, ALT, AST, and
Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:  doxorubicin CONVENTIONAL for 30 minutes.
DAY 15 FOLLOW-UP
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:40:06 AM Page 2 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, BUN, Creatinine, Total Bilirubin, ALT, AST, and
Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:  doxorubicin CONVENTIONAL for 30 minutes.
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, BUN, Creatinine, Total Bilirubin, ALT, AST, and
Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:  doxorubicin CONVENTIONAL for 30 minutes.
DAY 36 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, BUN, Creatinine, Total Bilirubin, ALT, AST, and
Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:  doxorubicin CONVENTIONAL for 30 minutes.
Day 8, Cycle 1 –  Planned for 11/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer (Advanced); THERAPY: doxorubicin CONVENTIONAL 10 mg/m2 IV prior to
radiotherapy on Day 1, 8, 15, 22, 29, 36; CYCLE LENGTH: 42 days; COURSE: 1 cycle
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin
greater than ULN
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:40:06 AM Page 3 of 9
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
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 10 mg/m2 (Treatment Plan)
10 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
IV side arm push 3-5 mL/minute into running IV.
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: Anaplastic Thyroid Cancer (Advanced); THERAPY: doxorubicin CONVENTIONAL 10 mg/m2 IV prior to
radiotherapy on Day 1, 8, 15, 22, 29, 36; CYCLE LENGTH: 42 days; COURSE: 1 cycle
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:40:06 AM Page 4 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin
greater than ULN
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.
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
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 10 mg/m2 (Treatment Plan)
10 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
IV side arm push 3-5 mL/minute into running IV.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 –  Planned for 12/4/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:40:06 AM Page 5 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

DISEASE: Anaplastic Thyroid Cancer (Advanced); THERAPY: doxorubicin CONVENTIONAL 10 mg/m2 IV prior to
radiotherapy on Day 1, 8, 15, 22, 29, 36; CYCLE LENGTH: 42 days; COURSE: 1 cycle
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin
greater than ULN
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:40:06 AM Page 6 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Pre-Medications
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 10 mg/m2 (Treatment Plan)
10 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
IV side arm push 3-5 mL/minute into running IV.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 1 –  Planned for 12/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer (Advanced); THERAPY: doxorubicin CONVENTIONAL 10 mg/m2 IV prior to
radiotherapy on Day 1, 8, 15, 22, 29, 36; CYCLE LENGTH: 42 days; COURSE: 1 cycle
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin
greater than ULN
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:40:06 AM Page 7 of 9
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
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
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 10 mg/m2 (Treatment Plan)
10 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
IV side arm push 3-5 mL/minute into running IV.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 36, Cycle 1 –  Planned for 12/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer (Advanced); THERAPY: doxorubicin CONVENTIONAL 10 mg/m2 IV prior to
radiotherapy on Day 1, 8, 15, 22, 29, 36; CYCLE LENGTH: 42 days; COURSE: 1 cycle
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:40:06 AM Page 8 of 9
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, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin
greater than ULN
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.
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
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 10 mg/m2 (Treatment Plan)
10 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
IV side arm push 3-5 mL/minute into running IV.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:40:06 AM Page 9 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org