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CSC Lung Bevacizumab(21D1) Cisplatin(21D1) Pemetrexed(21D1) Followed by Bevacizumab(21D1) Ver 2-14-17 (HL 6312)

CSC Lung Bevacizumab(21D1) Cisplatin(21D1) Pemetrexed(21D1) Followed by Bevacizumab(21D1) Ver 2-14-17 (HL 6312) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG BEVACIZUMAB(21D:1)/CISPLATIN(21D:1)/PEMETREXED(21D:1) FOLLOWED BY BEVACIZUMAB(21D:1) VER:
2-14-17 – Properties
Pre-Cycle – 2/7/2017 through 2/13/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; 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+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
URINALYSIS, NO MICROSCOPY
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following chemotherapy., 80 mg, Disp-2 cap, R-5, 1 X DAILY starting S, Local
Printer
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
dexamethasone (DECADRON) 4 MG tab
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2/14/2017 8:06:41 AM Page 1 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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-5, starting S, Local
Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
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 – 2/14/2017 through 3/6/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 2/14/2017
Treatment Plan Information
Reference Information (1)
MALIGNANT PLEURAL MESOTHELIOMA: Zalcman G, et al. Lancet 2016;387(10026):1405-14.
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; 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, Urine Protein.
Treatment Parameters
Hold treatment 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/min or Urine Protein greater than 100 mg/dL or Blood Pressure greater than 160/90 mmHg.
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 that patient has taken folic acid 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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications.
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
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 2 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 15 mg/kg in sodium chloride 0.9 % 100 mL bag
15 mg/kg, Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd dose over 30 minutes. Hypersensitivity
risk. See emergency medications. For first and second dose, patient should be treated in a location to optimize emergency care. If
infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
pemetrexed (ALIMTA) 500 mg/m2 in sodium chloride 0.9 % 100 mL bag
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
75 mg/m2, 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
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 3 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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, Urinalysis (no microscopy);
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, CISplatin, pemetrexed for 180 minutes.
Lab Only - Day 10, Cycle 1 – Planned for 2/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 3/7/2017 through 3/27/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 4 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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
URINALYSIS, NO MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Urine Protein.
Treatment Parameters
Hold treatment 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/min or Urine Protein greater than 100 mg/dL or Blood Pressure greater than 160/90 mmHg.
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 that patient has taken folic acid and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications.
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
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 5 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pemetrexed (ALIMTA) 500 mg/m2 in sodium chloride 0.9 % 100 mL bag
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
bevacizumab (AVASTIN) 15 mg/kg in sodium chloride 0.9 % 100 mL bag
15 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd dose over 30 minutes. If infusion-related
reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
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, Urinalysis (no microscopy);
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, CISplatin, pemetrexed for 150 minutes.
Lab Only - Day 10, Cycle 2 – Planned for 3/16/2017
Treatment Plan Information
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 6 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 3/28/2017 through 4/17/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 3/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 7 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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
URINALYSIS, NO MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Urine Protein.
Treatment Parameters
Hold treatment 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/min or Urine Protein greater than 100 mg/dL or Blood Pressure greater than 160/90 mmHg.
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 that patient has taken folic acid and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications.
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
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 8 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cyanocobalamin (RUBIMIN) injection 1,000 mcg
1,000 mcg, Intramuscular, ONCE, 1 dose Starting when released
bevacizumab (AVASTIN) 15 mg/kg in sodium chloride 0.9 % 100 mL bag
15 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd dose over 30 minutes. If infusion-related
reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
pemetrexed (ALIMTA) 500 mg/m2 in sodium chloride 0.9 % 100 mL bag
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
75 mg/m2, 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, Urinalysis (no microscopy);
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, CISplatin, pemetrexed for 150 minutes.
Lab Only - Day 10, Cycle 3 – Planned for 4/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
cyanocobalamin (vitamin B12) 1 mg IM once every 9 weeks to begin at least 1 week prior to pemetrexed and to continue until
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 9 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

pemetrexed is discontinued; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 4/18/2017 through 5/8/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 4/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 10 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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
URINALYSIS, NO MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Urine Protein.
Treatment Parameters
Hold treatment 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/min or Urine Protein greater than 100 mg/dL or Blood Pressure greater than 160/90 mmHg.
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 that patient has taken folic acid and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications.
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
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 11 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 15 mg/kg in sodium chloride 0.9 % 100 mL bag
15 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd dose over 30 minutes. If infusion-related
reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
pemetrexed (ALIMTA) 500 mg/m2 in sodium chloride 0.9 % 100 mL bag
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
75 mg/m2, 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, Urinalysis (no microscopy);
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, CISplatin, pemetrexed for 150 minutes.
Lab Only - Day 10, Cycle 4 – Planned for 4/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; 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
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Zztestonc,Fiona F [2462287]
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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 – 5/9/2017 through 5/29/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 5/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
MAGNESIUM
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Zztestonc,Fiona F [2462287]
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Expected-S+21 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Urine Protein.
Treatment Parameters
Hold treatment 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/min or Urine Protein greater than 100 mg/dL or Blood Pressure greater than 160/90 mmHg.
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 that patient has taken folic acid and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications.
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
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 14 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 15 mg/kg in sodium chloride 0.9 % 100 mL bag
15 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd dose over 30 minutes. If infusion-related
reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
pemetrexed (ALIMTA) 500 mg/m2 in sodium chloride 0.9 % 100 mL bag
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
75 mg/m2, 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, Urinalysis (no microscopy);
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab, CISplatin, pemetrexed for 150 minutes.
Lab Only - Day 10, Cycle 5 – Planned for 5/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 15 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Cycle 6 – 5/30/2017 through 6/19/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, Urine Protein.
Treatment Parameters
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 16 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Hold treatment 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/min or Urine Protein greater than 100 mg/dL or Blood Pressure greater than 160/90 mmHg.
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 that patient has taken folic acid and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications.
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
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cyanocobalamin (RUBIMIN) injection 1,000 mcg
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Zztestonc,Fiona F [2462287]
2/14/2017 8:06:41 AM Page 17 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

1,000 mcg, Intramuscular, ONCE, 1 dose Starting when released
bevacizumab (AVASTIN) 15 mg/kg in sodium chloride 0.9 % 100 mL bag
15 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd dose over 30 minutes. If infusion-related
reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
pemetrexed (ALIMTA) 500 mg/m2 in sodium chloride 0.9 % 100 mL bag
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
75 mg/m2, 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: Urinalysis (no microscopy); CHEMOTHERAPY
ROOM APPOINTMENT: bevacizumab for 60 minutes.
Lab Only - Day 10, Cycle 6 – Planned for 6/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 6/20/2017 through 7/10/2017 (21 days), Planned
Day 1, Cycle 7 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
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DISEASE: Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Tunica Vaginalis Testis Mesothelioma; THERAPY:
bevacizumab 15 mg/kg IV Day 1, pemetrexed 500 mg/m2 IV Day 1, CISplatin 75 mg/m2 IV Day 1, folic acid at least 300 mcg by
mouth once daily to begin at least 1 week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed,
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; CYCLE LENGTH: 21 days; COURSE: 6 cycles followed by THERAPY: bevacizumab 15 mg/kg IV Day
1; 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
URINALYSIS, NO MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urine protein.
Treatment Parameters
Hold and notify authorizing prescriber for Urine protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to
160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 15 mg/kg in sodium chloride 0.9 % 100 mL bag
15 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd dose over 30 minutes. If infusion-related
reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: Urinalysis (no microscopy); CHEMOTHERAPY
ROOM APPOINTMENT: bevacizumab for 60 minutes.
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