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

/clinical/cckm-tools/content/beacon-protocols/sarcoma/name-109725-en.cckm

201611334

page

100

UWHC,UWMF,

Tools,

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

CSC Sarcoma Eribulin (21D:1,8) VER 10-31-16 (HL 6152)

CSC Sarcoma Eribulin (21D:1,8) VER 10-31-16 (HL 6152) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA ERIBULIN (21D:1,8) VER: 10-31-16 – Properties
Pre-Cycle – 11/22/2016 through 11/28/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
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
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S Approximate, Expires-S+365, 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 – 11/29/2016 through 12/19/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/29/2016
Treatment Plan Information
Reference Information (1)
SARCOMA: Schöffski P, et al. Lancet 2016;387(10028):1629-37.
Reference Information (2)
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 1 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

SARCOMA: Schöffski P, et al. Lancet Oncol 2011;12(11):1045-52.
Reference Information (3)
SARCOMA: Halaven® [package insert]. Woodcliff Lake, NJ:Eisai Inc; 2016.
Reference Information (4)
SARCOMA: National Comprehensive Cancer Network. Soft Tissue Sarcoma NCCN Guidelines (Version 2.2016).
https://www.nccn.org/professionals/physician_gls/pdf/sarcoma.pdf. Updated 2-19-16. Accessed September 7, 2016.
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
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: CBC, ANC, Total Bilirubin, Creatinine, Magnesium, Potassium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin greater than 1.5 X
ULN or Creatinine greater than 1.5 X ULN or Magnesium outside of normal limits or Potassium outside of normal limits.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of toxicity.
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.
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 2 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
eriBULin mesylate (HALAVEN) injection 2.5 mg
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 2 to 5 minutes. Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: eriBULin for 30 minutes.
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), Creatinine,
AST, Total Bilirubin, Alkaline Phosphatase, Calcium, Magnesium, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: eriBULin
for 30 minutes.
Day 8, Cycle 1 – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
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.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of toxicity.
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.
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 3 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
eriBULin mesylate (HALAVEN) injection 2.5 mg
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 2 to 5 minutes. Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/20/2016 through 1/9/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
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
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 4 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin, Creatinine, Magnesium, Potassium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin greater than 1.5 X
ULN or Creatinine greater than 1.5 X ULN or Magnesium outside of normal limits or Potassium outside of normal limits.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of toxicity.
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
eriBULin mesylate (HALAVEN) injection 2.5 mg
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 2 to 5 minutes. Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: eriBULin for 30 minutes.
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), Creatinine,
AST, Total Bilirubin, Alkaline Phosphatase, Calcium, Magnesium, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: eriBULin
for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 5 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 8, Cycle 2 – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
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.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of toxicity.
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]
11/29/2016 1:24:36 PM Page 6 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

eriBULin mesylate (HALAVEN) injection 2.5 mg
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer over 2 to 5 minutes. Do not dilute in or administer through an IV line containing solutions with dextrose
or other medicinal products
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/10/2017 through 1/30/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 1/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
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
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 7 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin, Creatinine, Magnesium, Potassium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin greater than 1.5 X
ULN or Creatinine greater than 1.5 X ULN or Magnesium outside of normal limits or Potassium outside of normal limits.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of toxicity.
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
eriBULin mesylate (HALAVEN) injection 2.5 mg
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 2 to 5 minutes. Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: eriBULin for 30 minutes.
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), Creatinine,
AST, Total Bilirubin, Alkaline Phosphatase, Calcium, Magnesium, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: eriBULin
for 30 minutes.
Day 8, Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
IV Access
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 8 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of toxicity.
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
eriBULin mesylate (HALAVEN) injection 2.5 mg
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 2 to 5 minutes. Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 1/31/2017 through 2/20/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/31/2017
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 9 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
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
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin, Creatinine, Magnesium, Potassium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin greater than 1.5 X
ULN or Creatinine greater than 1.5 X ULN or Magnesium outside of normal limits or Potassium outside of normal limits.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of toxicity.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 10 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
eriBULin mesylate (HALAVEN) injection 2.5 mg
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 2 to 5 minutes. Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: eriBULin for 30 minutes.
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), Creatinine,
AST, Total Bilirubin, Alkaline Phosphatase, Calcium, Magnesium, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: eriBULin
for 30 minutes.
Day 8, Cycle 4 – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
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
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 11 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of toxicity.
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
eriBULin mesylate (HALAVEN) injection 2.5 mg
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 2 to 5 minutes. Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 2/21/2017 through 3/13/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 2/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
Consent
Verify Consent
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 12 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin, Creatinine, Magnesium, Potassium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin greater than 1.5 X
ULN or Creatinine greater than 1.5 X ULN or Magnesium outside of normal limits or Potassium outside of normal limits.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of toxicity.
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]
11/29/2016 1:24:36 PM Page 13 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
eriBULin mesylate (HALAVEN) injection 2.5 mg
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 2 to 5 minutes. Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: eriBULin for 30 minutes.
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), Creatinine,
AST, Total Bilirubin, Alkaline Phosphatase, Calcium, Magnesium, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: eriBULin
for 30 minutes.
Day 8, Cycle 5 – Planned for 2/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
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.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of toxicity.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 14 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
eriBULin mesylate (HALAVEN) injection 2.5 mg
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 2 to 5 minutes. Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 3/14/2017 through 4/3/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 3/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
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
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 15 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin, Creatinine, Magnesium, Potassium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin greater than 1.5 X
ULN or Creatinine greater than 1.5 X ULN or Magnesium outside of normal limits or Potassium outside of normal limits.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of toxicity.
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
eriBULin mesylate (HALAVEN) injection 2.5 mg
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 2 to 5 minutes. Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products
Follow-Up
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ZZtestonc,Andrew [2428787]
11/29/2016 1:24:36 PM Page 16 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: eriBULin for 30 minutes.
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), Creatinine,
AST, Total Bilirubin, Alkaline Phosphatase, Calcium, Magnesium, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: eriBULin
for 30 minutes.
Day 8, Cycle 6 – Planned for 3/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: eriBULin 1.4 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: until
disease progression.
Note to All Staff (1)
This regimen is Chemotherapy Council approved for patients with unresectable or metastatic liposarcoma who have received a prior
anthracycline-containing regimen.
Note to All Staff (2)
Consider ECG monitoring for patients with congestive heart failure (CHF), bradyarrhythmias, or electrolyte abnormalities.
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.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of peripheral motor and sensory neuropathy. Notify physician for any concerns of toxicity.
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]
11/29/2016 1:24:36 PM Page 17 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
eriBULin mesylate (HALAVEN) injection 2.5 mg
2.5 mg (rounded from 2.506 mg = 1.4 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 2 to 5 minutes. Do not dilute in or administer through an IV line containing solutions with dextrose or other medicinal
products
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]
11/29/2016 1:24:36 PM Page 18 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org