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201706165

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UWHC,UWMF,

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

CSC Sarcoma Doxorubicin Liposomal(21D:1) VER 5-1-17 (HL 3590)

CSC Sarcoma Doxorubicin Liposomal(21D:1) VER 5-1-17 (HL 3590) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA DOXORUBICIN LIPOSOMAL(21D1) VER 5-1-17 (HL 3590) – Properties
Pre-Cycle – 6/6/2017 through 6/12/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Kaposi Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 20 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 cycles.
Treatment Plan Summary (2)
DISEASE: Angiosarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+122
ELECTROLYTES
Expected-S Approximate, Expires-S+122
GLUCOSE
Expected-S Approximate, Expires-S+122
BUN
Expected-S Approximate, Expires-S+122
CREATININE
Expected-S Approximate, Expires-S+397
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 – 6/13/2017 through 7/3/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Reference Information (1)
KAPOSI SARCOMA: Stewart S, et al. J Clin Oncol 1998;16(2):683-91.
Reference Information (2)
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 1 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ANGIOSARCOMA: Skubitz KM, et al. Cancer 2005;104:361-6.
Treatment Plan Summary
DISEASE: Kaposi Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 20 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 cycles.
Treatment Plan Summary (2)
DISEASE: Angiosarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles or 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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of doxorubicin LIPOSOMAL and then every 30 minutes for
any subsequent doses.
Patient Instructions(1)
Educate patient about hand-foot syndrome and mucositis with doxorubicin LIPOSOMAL.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1 to 2 hours before liposomal DOXOrubicin to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of liposomal DOXOrubicin (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of liposomal DOXOrubicin (incompatible with NS).
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 2 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Infuse first dose at a rate of 50 mL/hr for 15 minutes then increase to 100 mL/hr for 15 minutes and if tolerated, increase to a final
rate to complete infusion in 60 minutes. If no infusion-related reactions occur, subsequent doses can be given over 60 minutes.
Incompatible with NS. Flush line with 50 mL D5W before and after infusion.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Total Bilirubin, AST, ALT, Alkaline Phosphatase, Electrolytes, Glucose, BUN, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin LIPOSOMAL for 120 minutes.
Cycle 2 – 7/4/2017 through 7/24/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Kaposi Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 20 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 cycles.
Treatment Plan Summary (2)
DISEASE: Angiosarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles or 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+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 3 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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+122, Normal, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+397, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of doxorubicin LIPOSOMAL and then every 30 minutes for
any subsequent doses.
Patient Instructions(1)
Educate patient about hand-foot syndrome and mucositis with doxorubicin LIPOSOMAL.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1 to 2 hours before liposomal DOXOrubicin to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of liposomal DOXOrubicin (incompatible with NS).
dextrose 5 % infusion
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 4 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of liposomal DOXOrubicin (incompatible with NS).
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Infuse first dose at a rate of 50 mL/hr for 15 minutes then increase to 100 mL/hr for 15 minutes and if tolerated, increase to a final
rate to complete infusion in 60 minutes. If no infusion-related reactions occur, subsequent doses can be given over 60 minutes.
Incompatible with NS. Flush line with 50 mL D5W before and after infusion.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Total Bilirubin, AST, ALT, Alkaline Phosphatase, Electrolytes, Glucose, BUN, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin LIPOSOMAL for 120 minutes.
Cycle 3 – 7/25/2017 through 8/14/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Kaposi Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 20 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 cycles.
Treatment Plan Summary (2)
DISEASE: Angiosarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles or 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
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 5 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
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+122, Normal, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+397, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of doxorubicin LIPOSOMAL and then every 30 minutes for
any subsequent doses.
Patient Instructions(1)
Educate patient about hand-foot syndrome and mucositis with doxorubicin LIPOSOMAL.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 6 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1 to 2 hours before liposomal DOXOrubicin to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of liposomal DOXOrubicin (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of liposomal DOXOrubicin (incompatible with NS).
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Infuse first dose at a rate of 50 mL/hr for 15 minutes then increase to 100 mL/hr for 15 minutes and if tolerated, increase to a final
rate to complete infusion in 60 minutes. If no infusion-related reactions occur, subsequent doses can be given over 60 minutes.
Incompatible with NS. Flush line with 50 mL D5W before and after infusion.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Total Bilirubin, AST, ALT, Alkaline Phosphatase, Electrolytes, Glucose, BUN, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin LIPOSOMAL for 120 minutes.
Cycle 4 – 8/15/2017 through 9/4/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Kaposi Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 20 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 cycles.
Treatment Plan Summary (2)
DISEASE: Angiosarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 7 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
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+122, Normal, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+397, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of doxorubicin LIPOSOMAL and then every 30 minutes for
any subsequent doses.
Patient Instructions(1)
Educate patient about hand-foot syndrome and mucositis with doxorubicin LIPOSOMAL.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 8 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1 to 2 hours before liposomal DOXOrubicin to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of liposomal DOXOrubicin (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of liposomal DOXOrubicin (incompatible with NS).
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Infuse first dose at a rate of 50 mL/hr for 15 minutes then increase to 100 mL/hr for 15 minutes and if tolerated, increase to a final
rate to complete infusion in 60 minutes. If no infusion-related reactions occur, subsequent doses can be given over 60 minutes.
Incompatible with NS. Flush line with 50 mL D5W before and after infusion.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Total Bilirubin, AST, ALT, Alkaline Phosphatase, Electrolytes, Glucose, BUN, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin LIPOSOMAL for 120 minutes.
Cycle 5 – 9/5/2017 through 9/25/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Kaposi Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 20 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 cycles.
Treatment Plan Summary (2)
DISEASE: Angiosarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles or until disease progression.
Consent
Verify Consent
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 9 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
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+122, Normal, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+397, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of doxorubicin LIPOSOMAL and then every 30 minutes for
any subsequent doses.
Patient Instructions(1)
Educate patient about hand-foot syndrome and mucositis with doxorubicin LIPOSOMAL.
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
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 10 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1 to 2 hours before liposomal DOXOrubicin to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of liposomal DOXOrubicin (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of liposomal DOXOrubicin (incompatible with NS).
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Infuse first dose at a rate of 50 mL/hr for 15 minutes then increase to 100 mL/hr for 15 minutes and if tolerated, increase to a final
rate to complete infusion in 60 minutes. If no infusion-related reactions occur, subsequent doses can be given over 60 minutes.
Incompatible with NS. Flush line with 50 mL D5W before and after infusion.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Total Bilirubin, AST, ALT, Alkaline Phosphatase, Electrolytes, Glucose, BUN, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin LIPOSOMAL for 120 minutes.
Cycle 6 – 9/26/2017 through 10/16/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Kaposi Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 20 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 cycles.
Treatment Plan Summary (2)
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 11 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Angiosarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 6 to 8 cycles or 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+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
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+122, Normal, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+122, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+397, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of doxorubicin LIPOSOMAL and then every 30 minutes for
any subsequent doses.
Patient Instructions(1)
Educate patient about hand-foot syndrome and mucositis with doxorubicin LIPOSOMAL.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 12 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1 to 2 hours before liposomal DOXOrubicin to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of liposomal DOXOrubicin (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of liposomal DOXOrubicin (incompatible with NS).
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Infuse first dose at a rate of 50 mL/hr for 15 minutes then increase to 100 mL/hr for 15 minutes and if tolerated, increase to a final
rate to complete infusion in 60 minutes. If no infusion-related reactions occur, subsequent doses can be given over 60 minutes.
Incompatible with NS. Flush line with 50 mL D5W before and after infusion.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Total Bilirubin, AST, ALT, Alkaline Phosphatase, Electrolytes, Glucose, BUN, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin LIPOSOMAL for 120 minutes.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:05:02 PM Page 13 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org