/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/lung/,

/clinical/cckm-tools/content/beacon-protocols/lung/name-96926-en.cckm

201611333

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Lung

CSC Lung Bevacizumab(21D:1) CARBOplatin(21D:1) PACLItaxel(21D:1) VER 10-3-16 (HL333)

CSC Lung Bevacizumab(21D:1) CARBOplatin(21D:1) PACLItaxel(21D:1) VER 10-3-16 (HL333) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG BEVACIZUMAB(21D:1)/CARBOPLATIN(21D:1)/PACLITAXEL(21D:1) VER: 10-3-16 – Properties
Pre-Cycle – 11/21/2016 through 11/27/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day
1; bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg
IV Day 1 every 21 days at discretion of authorizing prescriber.
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
URINALYSIS, NO MICROSCOPY
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth 12 & 6 hours prior to PACLItaxel and 2 tabs once daily on Days 2, 3, and 4., Disp-50 tab, R-1, starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 11/28/2016 through 12/18/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Reference Information (1)
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 1 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

NON-SMALL CELL LUNG CANCER: Sandler, A. B., et al. Proc Am Soc Clin Onc 2005;Abs LBA4.
Treatment Plan Summary
DISEASE: Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day
1; bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg
IV Day 1 every 21 days at discretion of authorizing prescriber.
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 and resulted: WBC, ANC, Platelets, Creatinine, Urine Protein.
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 Urine
Protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
See emergency medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (3)
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.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 2 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 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.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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
PACLItaxel (TAXOL) 358 mg in dextrose 5 % 500 mL non-PVC bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Use non-PVC tubing and 0.22 micron in-line filter during administration. Hypersensitivity reaction to
PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency care. See
Emergency Medications.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
bevacizumab (AVASTIN) 1,050 mg in sodium chloride 0.9 % 100 mL bag
1,050 mg (15 mg/kg × 70 kg Treatment plan recorded weight), 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.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: 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, and
Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel, CARBOplatin and bevacizumab for 360
minutes
Lab Only - Day 10, Cycle 1 – Planned for 12/7/2016
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 3 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin
(AUC = 6) IV Day 1; bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be
followed by bevacizumab 15mg/kg IV Day 1 every 21 days at discretion of authorizing prescriber.
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
ELECTROLYTES
Expected-S+9 Approximate, Expires-S+365, Routine
BUN
Expected-S+9 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+9 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+9 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+9 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+9 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+9 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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 – 12/19/2016 through 1/8/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Sandler, A. B., et al. Proc Am Soc Clin Onc 2005;Abs LBA4.
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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,Andrew [2428787]
11/28/2016 1:32:32 PM Page 4 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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
URINALYSIS, NO MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urine Protein.
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 Urine
Protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
See emergency medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (3)
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.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 5 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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
PACLItaxel (TAXOL) 358 mg in dextrose 5 % 500 mL non-PVC bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Use non-PVC tubing and 0.22 micron in-line filter during administration. Hypersensitivity reaction to
PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency care. See
Emergency Medications.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
bevacizumab (AVASTIN) 1,050 mg in sodium chloride 0.9 % 100 mL bag
1,050 mg (15 mg/kg × 70 kg Treatment plan recorded weight), 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 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 6 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: 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, and Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT:
PACLItaxel, CARBOplatin and bevacizumab for 360 minutes
Lab Only - Day 10, Cycle 2 – Planned for 12/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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 – 1/9/2017 through 1/29/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 1/9/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Sandler, A. B., et al. Proc Am Soc Clin Onc 2005;Abs LBA4.
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 7 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
URINALYSIS, NO MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urine Protein.
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 Urine
Protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
See emergency medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (3)
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.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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,Andrew [2428787]
11/28/2016 1:32:32 PM Page 8 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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
PACLItaxel (TAXOL) 358 mg in dextrose 5 % 500 mL non-PVC bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Use non-PVC tubing and 0.22 micron in-line filter during administration. Hypersensitivity reaction to
PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency care. See
Emergency Medications.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
bevacizumab (AVASTIN) 1,050 mg in sodium chloride 0.9 % 100 mL bag
1,050 mg (15 mg/kg × 70 kg Treatment plan recorded weight), 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 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: 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, and
Urinanlysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel, CARBOplatin and bevacizumab for 360 minutes
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 9 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Lab Only - Day 10, Cycle 3 – Planned for 1/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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 – 1/30/2017 through 2/19/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/30/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Sandler, A. B., et al. Proc Am Soc Clin Onc 2005;Abs LBA4.
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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,Andrew [2428787]
11/28/2016 1:32:32 PM Page 10 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
URINALYSIS, NO MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urine Protein.
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 Urine
Protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
See emergency medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (3)
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.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 11 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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
PACLItaxel (TAXOL) 358 mg in dextrose 5 % 500 mL non-PVC bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Use non-PVC tubing and 0.22 micron in-line filter during administration. Hypersensitivity reaction to
PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency care. See
Emergency Medications.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
bevacizumab (AVASTIN) 1,050 mg in sodium chloride 0.9 % 100 mL bag
1,050 mg (15 mg/kg × 70 kg Treatment plan recorded weight), 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 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: 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, and
Urinanlysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel, CARBOplatin and bevacizumab for 360 minutes
Lab Only - Day 10, Cycle 4 – Planned for 2/8/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 12 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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 – 2/20/2017 through 3/12/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 2/20/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Sandler, A. B., et al. Proc Am Soc Clin Onc 2005;Abs LBA4.
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 13 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
URINALYSIS, NO MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urine Protein.
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 Urine
Protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
See emergency medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (3)
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.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 14 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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
PACLItaxel (TAXOL) 358 mg in dextrose 5 % 500 mL non-PVC bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Use non-PVC tubing and 0.22 micron in-line filter during administration. Hypersensitivity reaction to
PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency care. See
Emergency Medications.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
bevacizumab (AVASTIN) 1,050 mg in sodium chloride 0.9 % 100 mL bag
1,050 mg (15 mg/kg × 70 kg Treatment plan recorded weight), 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 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: 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, and
Urinanlysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel, CARBOplatin and bevacizumab for 360 minutes
Lab Only - Day 10, Cycle 5 – Planned for 3/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 15 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 – 3/13/2017 through 4/2/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 3/13/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Sandler, A. B., et al. Proc Am Soc Clin Onc 2005;Abs LBA4.
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 16 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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 and resulted: WBC, ANC, Platelets, Creatinine, Urine Protein.
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 Urine
Protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
See emergency medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (3)
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.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 17 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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
PACLItaxel (TAXOL) 358 mg in dextrose 5 % 500 mL non-PVC bag
358 mg (200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Use non-PVC tubing and 0.22 micron in-line filter during administration. Hypersensitivity reaction to
PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency care. See
Emergency Medications.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
bevacizumab (AVASTIN) 1,050 mg in sodium chloride 0.9 % 100 mL bag
1,050 mg (15 mg/kg × 70 kg Treatment plan recorded weight), 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 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: Urinalysis
without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 120 minutes
Lab Only - Day 10, Cycle 6 – Planned for 3/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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,Andrew [2428787]
11/28/2016 1:32:32 PM Page 18 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+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 – 4/3/2017 through 4/23/2017 (21 days), Planned
Day 1, Cycle 7 – Planned for 4/3/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Sandler, A. B., et al. Proc Am Soc Clin Onc 2005;Abs LBA4.
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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 (2)
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. Patient must be monitored for 30 minutes after first dose of bevacizumab.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 19 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 1,050 mg in sodium chloride 0.9 % 100 mL bag
1,050 mg (15 mg/kg × 70 kg Treatment plan recorded weight), 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) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: Urinalysis
without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 120 minutes
Cycle 8 – 4/24/2017 through 5/14/2017 (21 days), Planned
Day 1, Cycle 8 – Planned for 4/24/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Sandler, A. B., et al. Proc Am Soc Clin Onc 2005;Abs LBA4.
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 20 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 (2)
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. Patient must be monitored for 30 minutes after first dose of bevacizumab.
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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 1,050 mg in sodium chloride 0.9 % 100 mL bag
1,050 mg (15 mg/kg × 70 kg Treatment plan recorded weight), 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) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: Urinalysis
without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 120 minutes
Cycle 9 – 5/15/2017 through 6/4/2017 (21 days), Planned
Day 1, Cycle 9 – Planned for 5/15/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Sandler, A. B., et al. Proc Am Soc Clin Onc 2005;Abs LBA4.
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 21 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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 (2)
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. Patient must be monitored for 30 minutes after first dose of bevacizumab.
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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 22 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
bevacizumab (AVASTIN) 1,050 mg in sodium chloride 0.9 % 100 mL bag
1,050 mg (15 mg/kg × 70 kg Treatment plan recorded weight), 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) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: Urinalysis
without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 120 minutes
Cycle 10 – 6/5/2017 through 6/25/2017 (21 days), Planned
Day 1, Cycle 10 – Planned for 6/5/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Sandler, A. B., et al. Proc Am Soc Clin Onc 2005;Abs LBA4.
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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 (2)
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. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 23 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 1,050 mg in sodium chloride 0.9 % 100 mL bag
1,050 mg (15 mg/kg × 70 kg Treatment plan recorded weight), 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) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: Urinalysis
without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 120 minutes
Cycle 11 – 6/26/2017 through 7/16/2017 (21 days), Planned
Day 1, Cycle 11 – Planned for 6/26/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Sandler, A. B., et al. Proc Am Soc Clin Onc 2005;Abs LBA4.
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 24 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 (2)
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. Patient must be monitored for 30 minutes after first dose of bevacizumab.
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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 1,050 mg in sodium chloride 0.9 % 100 mL bag
1,050 mg (15 mg/kg × 70 kg Treatment plan recorded weight), 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) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: Urinalysis
without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 120 minutes
Cycle 12 – 7/17/2017 through 8/6/2017 (21 days), Planned
Day 1, Cycle 12 – Planned for 7/17/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 25 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (1)
NON-SMALL CELL LUNG CANCER: Sandler, A. B., et al. Proc Am Soc Clin Onc 2005;Abs LBA4.
Treatment Plan Summary
DISEASE:Non Small Cell Lung Cancer (Advanced). THERAPY: PACLItaxel 200 mg/m2 IV Day 1; CARBOplatin (AUC = 6) IV Day 1;
bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days. COURSE: 4 to 6 cycles. To be followed by bevacizumab 15 mg/kg IV
Day 1 every 21 days at discretion of authorizing prescriber.
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 (2)
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. Patient must be monitored for 30 minutes after first dose of bevacizumab.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 26 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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) 1,050 mg in sodium chloride 0.9 % 100 mL bag
1,050 mg (15 mg/kg × 70 kg Treatment plan recorded weight), 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) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: Urinalysis
without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 120 minutes
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ZZtestonc,Andrew [2428787]
11/28/2016 1:32:32 PM Page 27 of 27
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org