/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/,

/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/name-96890-en.cckm

201611327

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Hem - Lymphoma

CSC HEM Temozolomide(28D:1-5) VER 10-3-16 (HL 3197)

CSC HEM Temozolomide(28D:1-5) VER 10-3-16 (HL 3197) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM TEMOZOLOMIDE(28D:1-5) VER: 10-3-16 – Properties
Pre-Cycle – 11/15/2016 through 11/21/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma; THERAPY: temozolomide 150 mg/m2 by mouth daily Day 1 through 5; CYCLE LENGTH: 28
days; COURSE: maximum of 8 cycles.
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
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth one time daily. Take 1 tab orally before temozolomide and every 8h as needed for nausea, 8 mg, Disp-20
tab, R-5, 1 X DAILY starting S
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tab by mouth 2 times daily Sat,Sun., 1 tab, Disp-16 tab, R-5, 2 X DAILY SAT, SUN 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,
Local Printer
Cycle 1 – 11/22/2016 through 12/19/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Reference Information (1)
PRIMARY CNS LYMPHOMA: Enting R, et al. Neurology. 2004; 63:901-3
Reference Information (2)
PRIMARY CNS LYMPHOMA: Reni M, et al. Proc Am Soc Clin Oncol. 2003; 22: Abstract 2296
Reference Information (3)
PRIMARY CNS LYMPHOMA: Reni M, et al. J Natl Cancer Inst. 2000; 92(7):575-6
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma; THERAPY: temozolomide 150 mg/m2 by mouth daily Day 1 through 5; CYCLE LENGTH: 28
days; COURSE: maximum of 8 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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ZZtestonc,Andrew [2428787]
11/22/2016 12:43:26 PM Page 1 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 40 mL/min.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 5 MG cap
Take by mouth one time daily at bedtime. Take on Day 1 through 5 on empty stomach. Total daily dose = *** mg., R-0, 1 X
DAILY (HS) starting S, Local Printer
temozolomide (TEMODAR) 20 MG cap
Take by mouth one time daily at bedtime. Take on Day 1 through 5 on empty stomach. Total daily dose = *** mg., R-0, 1 X
DAILY (HS) starting S, Local Printer
temozolomide (TEMODAR) 100 MG cap
Take by mouth one time daily at bedtime. Take on Day 1 through 5 on empty stomach. Total daily dose = *** mg., R-0, 1 X
DAILY (HS) starting S, Local Printer
temozolomide (TEMODAR) 140 MG cap
Take by mouth one time daily at bedtime. Take on Day 1 through 5 on empty stomach. Total daily dose = *** mg., R-0, 1 X
DAILY (HS) starting S, Local Printer
temozolomide (TEMODAR) 180 MG cap
Take by mouth one time daily at bedtime. Take on Day 1 through 5 on empty stomach. Total daily dose = *** mg., R-0, 1 X
DAILY (HS) starting S, Local Printer
temozolomide (TEMODAR) 250 MG cap
Take by mouth one time daily at bedtime. Take on Day 1 through 5 on empty stomach. Total daily dose = *** mg., R-0, 1 X
DAILY (HS) starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (CBC with DIFF if drawn locally),
Creatinine
Cycle 2 – 12/20/2016 through 1/16/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/20/2016
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ZZtestonc,Andrew [2428787]
11/22/2016 12:43:26 PM Page 2 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma; THERAPY: temozolomide 150 mg/m2 by mouth daily Day 1 through 5; CYCLE LENGTH: 28
days; COURSE: maximum of 8 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 40 mL/min.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:43:26 PM Page 3 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

temozolomide (TEMODAR) 140 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily
dose = *** mg, R-0, 1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg., R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (CBC with DIFF if drawn locally),
Creatinine
Cycle 3 – 1/17/2017 through 2/13/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma; THERAPY: temozolomide 150 mg/m2 by mouth daily Day 1 through 5; CYCLE LENGTH: 28
days; COURSE: maximum of 8 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 40 mL/min.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/22/2016 12:43:26 PM Page 4 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg., R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (CBC with DIFF if drawn locally),
Creatinine
Cycle 4 – 2/14/2017 through 3/13/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma; THERAPY: temozolomide 150 mg/m2 by mouth daily Day 1 through 5; CYCLE LENGTH: 28
days; COURSE: maximum of 8 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:43:26 PM Page 5 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 40 mL/min.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
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ZZtestonc,Andrew [2428787]
11/22/2016 12:43:26 PM Page 6 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg., R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (CBC with DIFF if drawn locally),
Creatinine
Cycle 5 – 3/14/2017 through 4/10/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma; THERAPY: temozolomide 150 mg/m2 by mouth daily Day 1 through 5; CYCLE LENGTH: 28
days; COURSE: maximum of 8 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 40 mL/min.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:43:26 PM Page 7 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg., R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (CBC with DIFF if drawn locally),
Creatinine
Cycle 6 – 4/11/2017 through 5/8/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma; THERAPY: temozolomide 150 mg/m2 by mouth daily Day 1 through 5; CYCLE LENGTH: 28
days; COURSE: maximum of 8 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/22/2016 12:43:26 PM Page 8 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 75K/µL or Creatinine Clearance
less than 40 mL/min.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 180 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 140 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 100 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 20 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg., R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
temozolomide (TEMODAR) 5 MG cap
Take by mouth one time daily at bedtime. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, R-0,
1 X DAILY (HS) starting S, Local Printer
Round dose to available capsule sizes. Dosing based on *** mg/m2.
Follow-Up
DAY 29 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/22/2016 12:43:26 PM Page 9 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (CBC with DIFF if drawn locally),
Creatinine
ZZtestonc,Andrew [2428787]
11/22/2016 12:43:26 PM Page 10 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org