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/clinical/cckm-tools/content/beacon-protocols/lung/name-111808-en.cckm

20170127

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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,Lung

CSC LUNG CONCURRENT XRT CISPLATIN(21D1) PEMETREXED(21D1) VER 1-25-17 (6123)

CSC LUNG CONCURRENT XRT CISPLATIN(21D1) PEMETREXED(21D1) VER 1-25-17 (6123) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG CONCURRENT XRT CISPLATIN(21D:1)/PEMETREXED(21D:1) VER: 1-25-17 – Properties
Pre-Cycle – 1/18/2017 through 1/24/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 1/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
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+365, 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
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take Day 2 and Day 3 of each cycle following chemotherapy., 80 mg, Disp-2 cap, R-2, 1 X
DAILY starting S
dexamethasone (DECADRON) 4 MG tab
Take 1 tab twice daily the day prior, day of and day after chemo, then 2 tabs once daily X 2 days, Disp-48 tab, R-1, starting S, Local
Printer
To prevent pemetrexed rash and post chemotherapy nausea
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
ondansetron (ZOFRAN) 8 MG tab
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 1 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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
folic acid (FOLVITE) 1 MG tab
Take 1 tab by mouth one time daily., 1 mg, Disp-30 tab, R-11, 1 X DAILY starting S, Local Printer
Cycle 1 – 1/25/2017 through 2/14/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 1/25/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Senan S, et al. J Clin Oncol 2016;34(9):953-62.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
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 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient has taken folic acid daily during the last 10 days and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Verify Medication(s) Taken at Home(3)
Verify that patient has received cyanocobalamin and document in a progress note. Notify authorizing prescriber if patient has not
received medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
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.
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 2 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
CISplatin (PLATINOL) 272 mg in sodium chloride 0.9 % 1,000 mL bag
272 mg (rounded from 272.25 mg = 75 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 30 to 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Total Bilirubin, Magnesium; CHEMOTHERAPY
ROOM APPOINTMENT: CISplatin and pemetrexed for 150 minutes.
Lab Only - Day 10, Cycle 1 – Planned for 2/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 3 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 2/15/2017 through 3/7/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 2/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 4 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient has taken folic acid daily during the last 10 days and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Verify Medication(s) Taken at Home(3)
Verify that patient has received cyanocobalamin and document in a progress note. Notify authorizing prescriber if patient has not
received medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
CISplatin (PLATINOL) 272 mg in sodium chloride 0.9 % 1,000 mL bag
272 mg (rounded from 272.25 mg = 75 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 30 to 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 5 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Total Bilirubin, Magnesium; CHEMOTHERAPY
ROOM APPOINTMENT: CISplatin and pemetrexed for 150 minutes.
Lab Only - Day 10, Cycle 2 – Planned for 2/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 3/8/2017 through 3/28/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 3/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
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.
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 6 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
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 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient has taken folic acid daily during the last 10 days and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Verify Medication(s) Taken at Home(3)
Verify that patient has received cyanocobalamin and document in a progress note. Notify authorizing prescriber if patient has not
received medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
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
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 7 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
CISplatin (PLATINOL) 272 mg in sodium chloride 0.9 % 1,000 mL bag
272 mg (rounded from 272.25 mg = 75 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 30 to 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: pemetrexed for 30 minutes.
Lab Only - Day 10, Cycle 3 – Planned for 3/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
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
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 8 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 3/29/2017 through 4/18/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 3/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 9 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@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 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient has taken folic acid daily during the last 10 days and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Verify Medication(s) Taken at Home(3)
Verify that patient has received cyanocobalamin and document in a progress note. Notify authorizing prescriber if patient has not
received medication as prescribed.
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
Treatment Medications
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: pemetrexed for 30 minutes.
Lab Only - Day 10, Cycle 4 – Planned for 4/7/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 10 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 4/19/2017 through 5/9/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 4/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 11 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
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 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient has taken folic acid daily during the last 10 days and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Verify Medication(s) Taken at Home(3)
Verify that patient has received cyanocobalamin and document in a progress note. Notify authorizing prescriber if patient has not
received medication as prescribed.
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
Treatment Medications
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
Follow-Up
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 12 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: pemetrexed for 30 minutes.
Lab Only - Day 10, Cycle 5 – Planned for 4/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 5/10/2017 through 5/30/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 5/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
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
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 13 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
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 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient has taken folic acid daily during the last 10 days and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Verify Medication(s) Taken at Home(3)
Verify that patient has received cyanocobalamin and document in a progress note. Notify authorizing prescriber if patient has not
received medication as prescribed.
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,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 14 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
Treatment Medications
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: pemetrexed for 30 minutes.
Lab Only - Day 10, Cycle 6 – Planned for 5/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 5/31/2017 through 6/20/2017 (21 days), Planned
Day 1, Cycle 7 – Planned for 5/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 15 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
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 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient has taken folic acid daily during the last 10 days and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Verify Medication(s) Taken at Home(3)
Verify that patient has received cyanocobalamin and document in a progress note. Notify authorizing prescriber if patient has not
received medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 16 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
Treatment Medications
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider.
Lab Only - Day 10, Cycle 7 – Planned for 6/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1
concurrent with radiation therapy; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pemetrexed 500 mg/m2 IV
Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
NOTE: folic acid at least 300 mcg by mouth once daily and cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at
least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
1/25/2017 8:44:22 AM Page 17 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org