/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-96971-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 Gefitinib(21D:1-21) VER 10-3-16 (HL 5882)

CSC Lung Gefitinib(21D:1-21) VER 10-3-16 (HL 5882) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG GEFITINIB(21D:1-21) 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: gefitinib 250 mg by mouth once daily continuously; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Note to All Staff (1)
Tumors must have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations detected.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
ELECTROLYTES
Expected-S Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S Approximate, Expires-S+397, Routine
BUN
Expected-S Approximate, Expires-S+397, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
CALCIUM
Expected-S Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 11/28/2016 through 12/18/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Douillard JY, et al. Br J Cancer 2014;110(1):55-62.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:57:33 PM Page 1 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gefitinib 250 mg by mouth once daily continuously; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Note to All Staff (1)
Tumors must have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations detected.
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
ELECTROLYTES
Expected-S Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S Approximate, Expires-S+397, Routine
BUN
Expected-S Approximate, Expires-S+397, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
CALCIUM
Expected-S Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN, or AST greater than 5 X ULN, or ALT
greater than 5 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Advise patient that skin rash occurs in many patients receiving gefitinib and to contact provider if reaction occurs.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/28/2016 2:57:33 PM Page 2 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): gefitinib (dispensed Day 1 of each Cycle).
Take Home Medications
gefitinib (IRESSA) 250 MG tab
Take 1 tab by mouth one time daily., 250 mg, Disp-30 tab, R-0, 1 X DAILY starting S, Local Printer
Note to All Staff (1)
Gefitinib must be ordered through a specialty pharmacy. Please contact pharmacist for assistance in ordering. Pharmacist see
Reference Link section of Oncology Navigator for link to gefitinib ordering form.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of the next Cycle) RETURN TO THE CLINIC for an appointment with the provider; LABS: Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, and Alkaline Phosphatase.
Cycle 2 – 12/19/2016 through 1/8/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gefitinib 250 mg by mouth once daily continuously; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Note to All Staff (1)
Tumors must have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations detected.
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
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CALCIUM
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ZZtestonc,Andrew [2428787]
11/28/2016 2:57:33 PM Page 3 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN, or AST greater than 5 X ULN, or ALT
greater than 5 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Advise patient that skin rash occurs in many patients receiving gefitinib and to contact provider if reaction occurs.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): gefitinib (dispensed Day 1 of each Cycle).
Take Home Medications
gefitinib (IRESSA) 250 MG tab
Take 1 tab by mouth one time daily., 250 mg, Disp-30 tab, R-0, 1 X DAILY starting S, Local Printer
Note to All Staff (1)
Gefitinib must be ordered through a specialty pharmacy. Please contact pharmacist for assistance in ordering. Pharmacist see
Reference Link section of Oncology Navigator for link to gefitinib ordering form.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of the next Cycle) RETURN TO THE CLINIC for an appointment with the provider; LABS: Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, and Alkaline Phosphatase.
Cycle 3 – 1/9/2017 through 1/29/2017 (21 days), Planned
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ZZtestonc,Andrew [2428787]
11/28/2016 2:57:33 PM Page 4 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 3 – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gefitinib 250 mg by mouth once daily continuously; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Note to All Staff (1)
Tumors must have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations detected.
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
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN, or AST greater than 5 X ULN, or ALT
greater than 5 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Advise patient that skin rash occurs in many patients receiving gefitinib and to contact provider if reaction occurs.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:57:33 PM Page 5 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): gefitinib (dispensed Day 1 of each Cycle).
Take Home Medications
gefitinib (IRESSA) 250 MG tab
Take 1 tab by mouth one time daily., 250 mg, Disp-30 tab, R-0, 1 X DAILY starting S, Local Printer
Note to All Staff (1)
Gefitinib must be ordered through a specialty pharmacy. Please contact pharmacist for assistance in ordering. Pharmacist see
Reference Link section of Oncology Navigator for link to gefitinib ordering form.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of the next Cycle) RETURN TO THE CLINIC for an appointment with the provider; LABS: Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, and Alkaline Phosphatase.
Cycle 4 – 1/30/2017 through 2/19/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gefitinib 250 mg by mouth once daily continuously; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Note to All Staff (1)
Tumors must have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations detected.
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
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 2:57:33 PM Page 6 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN, or AST greater than 5 X ULN, or ALT
greater than 5 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Advise patient that skin rash occurs in many patients receiving gefitinib and to contact provider if reaction occurs.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): gefitinib (dispensed Day 1 of each Cycle).
Take Home Medications
gefitinib (IRESSA) 250 MG tab
Take 1 tab by mouth one time daily., 250 mg, Disp-30 tab, R-0, 1 X DAILY starting S, Local Printer
Note to All Staff (1)
Gefitinib must be ordered through a specialty pharmacy. Please contact pharmacist for assistance in ordering. Pharmacist see
Reference Link section of Oncology Navigator for link to gefitinib ordering form.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of the next Cycle) RETURN TO THE CLINIC for an appointment with the provider; LABS: Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, and Alkaline Phosphatase.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:57:33 PM Page 7 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 5 – 2/20/2017 through 3/12/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 2/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gefitinib 250 mg by mouth once daily continuously; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Note to All Staff (1)
Tumors must have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations detected.
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
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN, or AST greater than 5 X ULN, or ALT
greater than 5 X ULN.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/28/2016 2:57:33 PM Page 8 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Patient Instructions(1)
Advise patient that skin rash occurs in many patients receiving gefitinib and to contact provider if reaction occurs.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): gefitinib (dispensed Day 1 of each Cycle).
Take Home Medications
gefitinib (IRESSA) 250 MG tab
Take 1 tab by mouth one time daily., 250 mg, Disp-30 tab, R-0, 1 X DAILY starting S, Local Printer
Note to All Staff (1)
Gefitinib must be ordered through a specialty pharmacy. Please contact pharmacist for assistance in ordering. Pharmacist see
Reference Link section of Oncology Navigator for link to gefitinib ordering form.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of the next Cycle) RETURN TO THE CLINIC for an appointment with the provider; LABS: Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, and Alkaline Phosphatase.
Cycle 6 – 3/13/2017 through 4/2/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 3/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: gefitinib 250 mg by mouth once daily continuously; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Note to All Staff (1)
Tumors must have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations detected.
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
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 2:57:33 PM Page 9 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

BUN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN, or AST greater than 5 X ULN, or ALT
greater than 5 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Advise patient that skin rash occurs in many patients receiving gefitinib and to contact provider if reaction occurs.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): gefitinib (dispensed Day 1 of each Cycle).
Take Home Medications
gefitinib (IRESSA) 250 MG tab
Take 1 tab by mouth one time daily., 250 mg, Disp-30 tab, R-0, 1 X DAILY starting S, Local Printer
Note to All Staff (1)
Gefitinib must be ordered through a specialty pharmacy. Please contact pharmacist for assistance in ordering. Pharmacist see
Reference Link section of Oncology Navigator for link to gefitinib ordering form.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/28/2016 2:57:33 PM Page 10 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of the next Cycle) RETURN TO THE CLINIC for an appointment with the provider; LABS: Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, and Alkaline Phosphatase.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:57:33 PM Page 11 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org