/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-96960-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 Irinotecan(28D:1,8,15) VER 10-3-16 (HL 364)

CSC Lung Irinotecan(28D:1,8,15) VER 10-3-16 (HL 364) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG IRINOTECAN(28D:1,8,15) 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: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
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
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy., 8 mg, Disp-24 tab, R-5, 1 X DAILY starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting (For nausea)., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS
PRN starting S
loperamide (IMODIUM) 2 MG tab
Take 2 tab orally with 1st loose stool followed by 1 tab every 2h or 2 tab every 4h until no diarrhea x12h. Max dose=8 tab/day,
Disp-1 each, R-0, starting S, No Print
Counsel patient to purchase over the counter and provide instructions for use.
Cycle 1 – 11/28/2016 through 12/25/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/28/2016
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 1 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
SMALL CELL LUNG CANCER/ NON-SMALL CELL LUNG CANCER: Negoro, S., et al. Gan To Kagaku Ryoho 1991;18:1013-9.
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Total Bilirubin.
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 Total
Bilirubin greater than 2 mg/dL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 143.2 mg in dextrose 5 % 250 mL bag
143.2 mg (80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 2 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side
effects, Administer over 1 Minutes
May repeat x1 dose.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Total Bilirubun; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 120
minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Total Bilirubun; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 120
minutes.
DAY 29 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 and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: irinotecan for 120 minutes.
Day 8, Cycle 1 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Total Bilirubin.
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 Total
Bilirubin greater than 2 mg/dL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
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 3:03:41 PM Page 3 of 18
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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 143.2 mg in dextrose 5 % 250 mL bag
143.2 mg (80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Total Bilirubin.
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 Total
Bilirubin greater than 2 mg/dL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 4 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 143.2 mg in dextrose 5 % 250 mL bag
143.2 mg (80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/26/2016 through 1/22/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 5 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
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 Total
Bilirubin greater than 2 mg/dL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
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 3:03:41 PM Page 6 of 18
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 143.2 mg in dextrose 5 % 250 mL bag
143.2 mg (80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Total Bilirubun; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 120
minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 120
minutes.
DAY 29 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 and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: irinotecan for 120 minutes.
Day 8, Cycle 2 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Total Bilirubin.
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 Total
Bilirubin greater than 2 mg/dL
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 7 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 143.2 mg in dextrose 5 % 250 mL bag
143.2 mg (80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 8 of 18
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+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Total Bilirubin.
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 Total
Bilirubin greater than 2 mg/dL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 143.2 mg in dextrose 5 % 250 mL bag
143.2 mg (80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/23/2017 through 2/19/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/23/2017
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 9 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
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 Total
Bilirubin greater than 2 mg/dL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 10 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 143.2 mg in dextrose 5 % 250 mL bag
143.2 mg (80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Total Bilirubun; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 120
minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 120
minutes.
DAY 29 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 and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: irinotecan for 120 minutes.
Day 8, Cycle 3 – Planned for 1/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
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,Andrew [2428787]
11/28/2016 3:03:41 PM Page 11 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Total Bilirubin.
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 Total
Bilirubin greater than 2 mg/dL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 143.2 mg in dextrose 5 % 250 mL bag
143.2 mg (80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 – Planned for 2/6/2017
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 12 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Total Bilirubin.
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 Total
Bilirubin greater than 2 mg/dL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 143.2 mg in dextrose 5 % 250 mL bag
143.2 mg (80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 13 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 2/20/2017 through 3/19/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 14 of 18
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: WBC, ANC, Platelets, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
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 Total
Bilirubin greater than 2 mg/dL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 143.2 mg in dextrose 5 % 250 mL bag
143.2 mg (80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Total Bilirubun; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 120
minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 120
minutes.
DAY 29 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 and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: irinotecan for 120 minutes.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 15 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 8, Cycle 4 – Planned for 2/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Total Bilirubin.
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 Total
Bilirubin greater than 2 mg/dL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 143.2 mg in dextrose 5 % 250 mL bag
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 16 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

143.2 mg (80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 – Planned for 3/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced) and Non-Small Cell Lung Cancer (Adjuvant/ Advanced); THERAPY:
irinotecan 80mg/m2 IV Day 1, 8, and 15; CYCLE LENGTH: 28 Days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Total Bilirubin.
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 Total
Bilirubin greater than 2 mg/dL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
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 3:03:41 PM Page 17 of 18
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) 143.2 mg in dextrose 5 % 250 mL bag
143.2 mg (80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:03:41 PM Page 18 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org