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201611333

page

100

UWHC,UWMF,

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

CSC Lung Bevacizumab(21D:1) Cisplatin(21D:1) Gemcitabine(21D:1,8) VER 10-3-16 (HL 369)

CSC Lung Bevacizumab(21D:1) Cisplatin(21D:1) Gemcitabine(21D:1,8) VER 10-3-16 (HL 369) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG BEVACIZUMAB(21D:1)/CISPLATIN(21D:1)/GEMCITABINE(21D:1,8) 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: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following chemotherapy., 80 mg, Disp-2 cap, R-5, 1 X DAILY starting S
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
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S
Cycle 1 – 11/28/2016 through 12/18/2016 (21 days), Planned
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 1 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Manegold C, et al. J Clin Oncol 2007;ASCO Annual Meeting Proceedings Part I. 25(18S).
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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, Urinalysis.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Supplemental Electrolytes
Evaluate patient’s labs. If additional additives are required, order outside of the treatment plan with administration instructions
"Pharmacist to add to intravenous fluids".
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 2 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 143 mg in sodium chloride 0.9 % 1,000 mL bag
143 mg (rounded from 143.2 mg = 80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
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.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Total Bilirubin, Magnesium and Urinalysis without
microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine, CISplatin and bevacizumab for 240 minutes.
Day 8, Cycle 1 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 3 of 30
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
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 1:34:11 PM Page 4 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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: Manegold C, et al. J Clin Oncol 2007;ASCO Annual Meeting Proceedings Part I. 25(18S).
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urinalysis.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 5 of 30
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 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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Supplemental Electrolytes
Evaluate patient’s labs. If additional additives are required, order outside of the treatment plan with administration instructions
"Pharmacist to add to intravenous fluids".
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 143 mg in sodium chloride 0.9 % 1,000 mL bag
143 mg (rounded from 143.2 mg = 80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
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.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 6 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Total Bilirubin, Magnesium and Urinalysis without
microscopy; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine, CISplatin and bevacizumab for 240 minutes.
Day 8, Cycle 2 – Planned for 12/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 7 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 2 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
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: Manegold C, et al. J Clin Oncol 2007;ASCO Annual Meeting Proceedings Part I. 25(18S).
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 8 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urinalysis.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 9 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Supplemental Electrolytes
Evaluate patient’s labs. If additional additives are required, order outside of the treatment plan with administration
instructions "Pharmacist to add to intravenous fluids".
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 143 mg in sodium chloride 0.9 % 1,000 mL bag
143 mg (rounded from 143.2 mg = 80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
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.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: Urinalysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 90 minutes.
Day 8, Cycle 3 – Planned for 1/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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 1:34:11 PM Page 10 of 30
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 – Planned for 1/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 11 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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: Manegold C, et al. J Clin Oncol 2007;ASCO Annual Meeting Proceedings Part I. 25(18S).
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 12 of 30
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 and resulted: WBC, ANC, Platelets, Creatinine, Urinalysis.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Supplemental Electrolytes
Evaluate patient’s labs. If additional additives are required, order outside of the treatment plan with administration instructions
"Pharmacist to add to intravenous fluids".
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 143 mg in sodium chloride 0.9 % 1,000 mL bag
143 mg (rounded from 143.2 mg = 80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
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.
Conditional Orders
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 13 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: Urinalysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 90 minutes.
Day 8, Cycle 4 – Planned for 2/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 14 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 4 – Planned for 2/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
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: Manegold C, et al. J Clin Oncol 2007;ASCO Annual Meeting Proceedings Part I. 25(18S).
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 15 of 30
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+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
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urinalysis.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 16 of 30
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Supplemental Electrolytes
Evaluate patient’s labs. If additional additives are required, order outside of the treatment plan with administration instructions
"Pharmacist to add to intravenous fluids".
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 143 mg in sodium chloride 0.9 % 1,000 mL bag
143 mg (rounded from 143.2 mg = 80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
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.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: Urinalysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 90 minutes.
Day 8, Cycle 5 – Planned for 2/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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 1:34:11 PM Page 17 of 30
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 5 – Planned for 3/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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 1:34:11 PM Page 18 of 30
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
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: Manegold C, et al. J Clin Oncol 2007;ASCO Annual Meeting Proceedings Part I. 25(18S).
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 19 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

URINALYSIS, NO MICROSCOPY
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urinalysis.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Supplemental Electrolytes
Evaluate patient’s labs. If additional additives are required, order outside of the treatment plan with administration instructions
"Pharmacist to add to intravenous fluids".
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 143 mg in sodium chloride 0.9 % 1,000 mL bag
143 mg (rounded from 143.2 mg = 80 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 20 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd dose over 30 minutes. If infusion-related
reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: Urinalysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 90 minutes.
Day 8, Cycle 6 – Planned for 3/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 21 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 6 – Planned for 3/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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
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: Manegold C, et al. J Clin Oncol 2007;ASCO Annual Meeting Proceedings Part I. 25(18S).
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 22 of 30
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
URINALYSIS, NO MICROSCOPY
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urine protein.
Treatment Parameters
Hold and notify authorizing prescriber for Urine protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to
160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 23 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: Urinalysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 90 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: Manegold C, et al. J Clin Oncol 2007;ASCO Annual Meeting Proceedings Part I. 25(18S).
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urine protein.
Treatment Parameters
Hold and notify authorizing prescriber for Urine protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to
160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 24 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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) RETURN TO CLINIC for appointment with provider; LABS: Urinalysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 90 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: Manegold C, et al. J Clin Oncol 2007;ASCO Annual Meeting Proceedings Part I. 25(18S).
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urine protein.
Treatment Parameters
Hold and notify authorizing prescriber for Urine protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to
160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 25 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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) RETURN TO CLINIC for appointment with provider; LABS: Urinalysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 90 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: Manegold C, et al. J Clin Oncol 2007;ASCO Annual Meeting Proceedings Part I. 25(18S).
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
Consent
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 26 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urine protein.
Treatment Parameters
Hold and notify authorizing prescriber for Urine protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to
160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 27 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd dose over 30 minutes. If infusion-related
reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: Urinalysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 90 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: Manegold C, et al. J Clin Oncol 2007;ASCO Annual Meeting Proceedings Part I. 25(18S).
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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+14 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urine protein.
Treatment Parameters
Hold and notify authorizing prescriber for Urine protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to
160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 28 of 30
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) RETURN TO CLINIC for appointment with provider; LABS: Urinalysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 90 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
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Manegold C, et al. J Clin Oncol 2007;ASCO Annual Meeting Proceedings Part I. 25(18S).
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gemcitabine 1250mg/m2 IV on Day 1 and 8, CISplatin 80 mg/m2 IV
Day 1, bevacizumab 15 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles. To be followed by THERAPY:
bevacizumab 15mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: discretion of physician.
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+14 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 1:34:11 PM Page 29 of 30
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 (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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) RETURN TO CLINIC for appointment with provider; LABS: Urinalysis without microscopy;
CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab for 90 minutes.
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ZZtestonc,Andrew [2428787]
11/28/2016 1:34:11 PM Page 30 of 30
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org