/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-96797-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 Methotrexate(21D:1,8,15) VER 11-10-17 (HL 981)

CSC HEAD/NECK Methotrexate(21D:1,8,15) VER 11-10-17 (HL 981) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Head and Neck


CSC HEAD/NECK METHOTREXATE(21D:1,8,15) 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 (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed (For nausea)., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN 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
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:06:14 AM Page 1 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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: Schornagel JH, et al. J Clin Oncol 1995;13(7):1649-55.
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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
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.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
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 10:06:14 AM Page 2 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
methotrexate for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
methotrexate for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, BUN, Creatinine,
Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: methotrexate for 30 minutes.
Day 8, Cycle 1 –  Planned for 11/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 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
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
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:06:14 AM Page 3 of 26
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
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 (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
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 10:06:14 AM Page 4 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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
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.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
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 (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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
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 10:06:14 AM Page 5 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
ELECTROLYTES
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
CALCIUM
Expected: S+7 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
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
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+7 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
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
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 10:06:14 AM Page 6 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
methotrexate for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
methotrexate for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, BUN, Creatinine,
Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: methotrexate for 30 minutes.
Day 8, Cycle 2 –  Planned for 12/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
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 10:06:14 AM Page 7 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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
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.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
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 (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
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 10:06:14 AM Page 8 of 26
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
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 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
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.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
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 (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; CYCLE LENGTH: 21 days; COURSE: until disease progression
Consent
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 10:06:14 AM Page 9 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
ELECTROLYTES
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
CALCIUM
Expected: S+7 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
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
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+7 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
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
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:06:14 AM Page 10 of 26
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
methotrexate for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
methotrexate for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, BUN, Creatinine,
Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: methotrexate for 30 minutes.
Day 8, Cycle 3 –  Planned for 1/1/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
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
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:06:14 AM Page 11 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 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
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.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
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 (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:06:14 AM Page 12 of 26
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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 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
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.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
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
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 10:06:14 AM Page 13 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Day 1, Cycle 4 –  Planned for 1/15/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
ELECTROLYTES
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
CALCIUM
Expected: S+7 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
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
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
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 10:06:14 AM Page 14 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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
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.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
methotrexate for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
methotrexate for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, BUN, Creatinine,
Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: methotrexate for 30 minutes.
Day 8, Cycle 4 –  Planned for 1/22/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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
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 10:06:14 AM Page 15 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 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
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.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 –  Planned for 1/29/2018
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 10:06:14 AM Page 16 of 26
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: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 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
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.
Treatment Medications
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 10:06:14 AM Page 17 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
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 (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
ELECTROLYTES
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
CALCIUM
Expected: S+7 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
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 10:06:14 AM Page 18 of 26
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
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+7 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
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.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
methotrexate for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
methotrexate for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, BUN, Creatinine,
Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: methotrexate for 30 minutes.
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 10:06:14 AM Page 19 of 26
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 (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 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
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.
Treatment Medications
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 10:06:14 AM Page 20 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
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 (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 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
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.
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 10:06:14 AM Page 21 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
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: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
ELECTROLYTES
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
CALCIUM
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
Actions
Actions
Actions
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:06:14 AM Page 22 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

ALBUMIN
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
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
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+7 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
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.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
methotrexate for 30 minutes.
DAY 15 FOLLOW-UP
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 10:06:14 AM Page 23 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:
methotrexate for 30 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, BUN, Creatinine,
Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: methotrexate for 30 minutes.
Day 8, Cycle 6 –  Planned for 3/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 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
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
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 10:06:14 AM Page 24 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
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 (Adjuvant/Advanced); THERAPY: methotrexate 40 to 60 mg/m2 IV weekly on Days 1, 8,
15; 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+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 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 10:06:14 AM Page 25 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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.
Treatment Medications
methotrexate PF (TREXALL) injection
Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute.
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
Zztestonc,PedsBeiber [2668824]
11/13/2017 10:06:14 AM Page 26 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org