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201611333

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UWHC,UWMF,

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

CSC Melanoma Temozolomide(28D:1-5) VER 10-3-16 (HL 948)

CSC Melanoma Temozolomide(28D:1-5) VER 10-3-16 (HL 948) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Melanoma


CSC MELANOMA TEMOZOLOMIDE(28D:1-5) 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: Melanoma (Advanced); THERAPY: temozolomide 200 mg/m2 by mouth once daily on Day 1 through Day 5; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab orally before temozolomide and every 8h as needed for nausea, Disp-30 tab, R-5, 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,
Local Printer
Cycle 1 – 11/28/2016 through 12/25/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Reference Information (1)
MELANOMA: Middleton et al, J Clin Oncol 2000;18:158-66.
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: temozolomide 200 mg/m2 by mouth once daily on Day 1 through Day 5; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:52:54 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

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, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than or equal to 1.6 mg/dL, AST greater than 2 X ULN, Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
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): temozolomide (Dispensed on Day 1 of each
cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 250 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 180 MG cap
Take 2 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 360 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 140 MG cap
Take 3 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 420 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 100 MG cap
Take 4 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 400 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
Follow-Up
200 mg/m2 (358 mg = 1.432 cap) cannot be prescribed using the selected product.
The nearest available dose is 250 mg (140 mg/m2).
200 mg/m2 (358 mg = 2.5571 cap) cannot be prescribed using the selected product.
The nearest available dose is 420 mg (235 mg/m2).
200 mg/m2 (358 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 400 mg (223 mg/m2).
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ZZtestonc,Andrew [2428787]
11/28/2016 3:52:54 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

DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Alkaline Phospatase, AST, ALT, Total Bilirubin, LDH.
Cycle 2 – 12/26/2016 through 1/22/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/26/2016
Treatment Plan Information
Reference Information (1)
MELANOMA: Middleton et al, J Clin Oncol 2000;18:158-66.
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: temozolomide 200 mg/m2 by mouth once daily on Day 1 through Day 5; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than or equal to 1.6 mg/dL, AST greater than 2 X ULN, Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:52:54 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

Patient Instructions(1)
Verify patient is taking ondansetron 8 mg by mouth daily Days 1 through 5 prior to temozolomide.
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): temozolomide (Dispensed on Day 1 of each
cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 250 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 180 MG cap
Take 2 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 360 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 140 MG cap
Take 3 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 420 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 100 MG cap
Take 4 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 400 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Alkaline Phospatase, AST, ALT, Total Bilirubin, LDH.
Cycle 3 – 1/23/2017 through 2/19/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/23/2017
Treatment Plan Information
Reference Information (1)
MELANOMA: Middleton et al, J Clin Oncol 2000;18:158-66.
Treatment Plan Summary
200 mg/m2 (358 mg = 1.432 cap) cannot be prescribed using the selected product.
The nearest available dose is 250 mg (140 mg/m2).
200 mg/m2 (358 mg = 2.5571 cap) cannot be prescribed using the selected product.
The nearest available dose is 420 mg (235 mg/m2).
200 mg/m2 (358 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 400 mg (223 mg/m2).
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ZZtestonc,Andrew [2428787]
11/28/2016 3:52:54 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

DISEASE: Melanoma (Advanced); THERAPY: temozolomide 200 mg/m2 by mouth once daily on Day 1 through Day 5; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than or equal to 1.6 mg/dL, AST greater than 2 X ULN, Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(1)
Verify patient is taking ondansetron 8 mg by mouth daily Days 1 through 5 prior to temozolomide.
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:52:54 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

Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on Day 1 of each
cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 250 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 180 MG cap
Take 2 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 360 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 140 MG cap
Take 3 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 420 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 100 MG cap
Take 4 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 400 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Alkaline Phospatase, AST, ALT, Total Bilirubin, LDH.
Cycle 4 – 2/20/2017 through 3/19/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/20/2017
Treatment Plan Information
Reference Information (1)
MELANOMA: Middleton et al, J Clin Oncol 2000;18:158-66.
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: temozolomide 200 mg/m2 by mouth once daily on Day 1 through Day 5; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
200 mg/m2 (358 mg = 1.432 cap) cannot be prescribed using the selected product.
The nearest available dose is 250 mg (140 mg/m2).
200 mg/m2 (358 mg = 2.5571 cap) cannot be prescribed using the selected product.
The nearest available dose is 420 mg (235 mg/m2).
200 mg/m2 (358 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 400 mg (223 mg/m2).
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ZZtestonc,Andrew [2428787]
11/28/2016 3:52:54 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

ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than or equal to 1.6 mg/dL, AST greater than 2 X ULN, Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(1)
Verify patient is taking ondansetron 8 mg by mouth daily Days 1 through 5 prior to temozolomide.
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): temozolomide (Dispensed on Day 1 of each
cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 250 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 180 MG cap
200 mg/m2 (358 mg = 1.432 cap) cannot be prescribed using the selected product.
The nearest available dose is 250 mg (140 mg/m2).
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ZZtestonc,Andrew [2428787]
11/28/2016 3:52:54 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

Take 2 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 360 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 140 MG cap
Take 3 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 420 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 100 MG cap
Take 4 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 400 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Alkaline Phospatase, AST, ALT, Total Bilirubin, LDH.
Cycle 5 – 3/20/2017 through 4/16/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/20/2017
Treatment Plan Information
Reference Information (1)
MELANOMA: Middleton et al, J Clin Oncol 2000;18:158-66.
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: temozolomide 200 mg/m2 by mouth once daily on Day 1 through Day 5; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
200 mg/m2 (358 mg = 2.5571 cap) cannot be prescribed using the selected product.
The nearest available dose is 420 mg (235 mg/m2).
200 mg/m2 (358 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 400 mg (223 mg/m2).
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ZZtestonc,Andrew [2428787]
11/28/2016 3:52:54 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

Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than or equal to 1.6 mg/dL, AST greater than 2 X ULN, Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Patient Instructions(1)
Verify patient is taking ondansetron 8 mg by mouth daily Days 1 through 5 prior to temozolomide.
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): temozolomide (Dispensed on Day 1 of each
cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 250 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 180 MG cap
Take 2 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 360 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 140 MG cap
Take 3 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 420 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 100 MG cap
Take 4 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 400 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
200 mg/m2 (358 mg = 1.432 cap) cannot be prescribed using the selected product.
The nearest available dose is 250 mg (140 mg/m2).
200 mg/m2 (358 mg = 2.5571 cap) cannot be prescribed using the selected product.
The nearest available dose is 420 mg (235 mg/m2).
200 mg/m2 (358 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 400 mg (223 mg/m2).
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ZZtestonc,Andrew [2428787]
11/28/2016 3:52:54 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

Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Alkaline Phospatase, AST, ALT, Total Bilirubin, LDH.
Cycle 6 – 4/17/2017 through 5/14/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/17/2017
Treatment Plan Information
Reference Information (1)
MELANOMA: Middleton et al, J Clin Oncol 2000;18:158-66.
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: temozolomide 200 mg/m2 by mouth once daily on Day 1 through Day 5; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than or equal to 1.6 mg/dL, AST greater than 2 X ULN, Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:52:54 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

Patient Instructions(1)
Verify patient is taking ondansetron 8 mg by mouth daily Days 1 through 5 prior to temozolomide.
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): temozolomide (Dispensed on Day 1 of each
cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
Take 1 cap by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 250 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 180 MG cap
Take 2 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 360 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 140 MG cap
Take 3 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 420 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
temozolomide (TEMODAR) 100 MG cap
Take 4 caps by mouth one time daily. Take Day 1 thru 5. Swallow whole on empty stomach. Total daily dose = *** mg, 400 mg
(rounded from 358 mg = 200 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY starting S
Round dose to nearest available capsule sizes.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Alkaline Phospatase, AST, ALT, Total Bilirubin, LDH.
200 mg/m2 (358 mg = 1.432 cap) cannot be prescribed using the selected product.
The nearest available dose is 250 mg (140 mg/m2).
200 mg/m2 (358 mg = 2.5571 cap) cannot be prescribed using the selected product.
The nearest available dose is 420 mg (235 mg/m2).
200 mg/m2 (358 mg = 3.58 cap) cannot be prescribed using the selected product.
The nearest available dose is 400 mg (223 mg/m2).
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ZZtestonc,Andrew [2428787]
11/28/2016 3:52:54 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