/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-97003-en.cckm

201706165

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UWHC,UWMF,

Tools,

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

CSC Sarcoma Doxorubicin Liposomal(28D:1) VER 5-1-17 (HL 957)

CSC Sarcoma Doxorubicin Liposomal(28D:1) VER 5-1-17 (HL 957) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA DOXORUBICIN LIPOSOMAL(28D1) VER 5-1-17 (HL 957) – 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: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28 days; COURSE: 6
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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
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+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Ejection Fraction
Confirm MUGA scan or ECHO-left ejection fraction reviewed by MD prior to Cycle 1 (required at baseline). Document confirmation of
review in progress note.
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 7/10/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Reference Information (1)
SARCOMA: Skubitz KM, et al. Cancer 2005;104:361-6.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 1 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28
days; COURSE: 6 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.
Verify Ejection Fraction
Confirm MUGA scan or ECHO-left ejection fraction reviewed by MD prior to Cycle 1 (required at baseline). Document confirmation of
review in progress note.
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.
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 2 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) 78 mg in dextrose 5 % 250 mL bag
78 mg (rounded from 78.4 mg = 40 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer FIRST dose as follows: start at 50 mL/hour for 15 Minutes: If tolerated increase to 100 mL/hour for 15 minutes: If
tolerated increase to final rate over 60 minutes. Subsequest doses may be administered over 60 minutes. Hypersensitivity reaction
to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
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), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
doxorubicin LIPOSOMAL for 90 minutes; RADIOLOGY: MD to order MUGA Scan or ECHO-left ejection fraction only as indicated.
Day 10 - Lab only, Cycle 1 – Planned for 6/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28 days; COURSE: 6
cycles or until disease progression.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/11/2017 through 8/7/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 3 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28 days; COURSE: 6
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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
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
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, 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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 4 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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 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) 78 mg in dextrose 5 % 250 mL bag
78 mg (rounded from 78.4 mg = 40 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer FIRST dose as follows: start at 50 mL/hour for 15 Minutes: If tolerated increase to 100 mL/hour for 15 minutes: If
tolerated increase to final rate over 60 minutes. Subsequest doses may be administered over 60 minutes. Hypersensitivity reaction
to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
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), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
doxorubicin LIPOSOMAL for 90 minutes; RADIOLOGY: MD to order MUGA Scan or ECHO-left ejection fraction only as indicated.
Day 10 - Lab only, Cycle 2 – Planned for 7/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28 days; COURSE: 6
cycles or until disease progression.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 5 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 8/8/2017 through 9/4/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28 days; COURSE: 6
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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
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
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 6 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, 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.
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
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
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 7 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) 78 mg in dextrose 5 % 250 mL bag
78 mg (rounded from 78.4 mg = 40 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer FIRST dose as follows: start at 50 mL/hour for 15 Minutes: If tolerated increase to 100 mL/hour for 15 minutes: If
tolerated increase to final rate over 60 minutes. Subsequest doses may be administered over 60 minutes. Hypersensitivity reaction
to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
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), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
doxorubicin LIPOSOMAL for 90 minutes; RADIOLOGY: MD to order MUGA Scan or ECHO-left ejection fraction only as indicated.
Day 10 - Lab only, Cycle 3 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28 days; COURSE: 6
cycles or until disease progression.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 9/5/2017 through 10/2/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28 days; COURSE: 6
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 12:06:13 PM Page 8 of 15
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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
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
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, 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.
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).
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 9 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) 78 mg in dextrose 5 % 250 mL bag
78 mg (rounded from 78.4 mg = 40 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer FIRST dose as follows: start at 50 mL/hour for 15 Minutes: If tolerated increase to 100 mL/hour for 15 minutes: If
tolerated increase to final rate over 60 minutes. Subsequest doses may be administered over 60 minutes. Hypersensitivity reaction
to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
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), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
doxorubicin LIPOSOMAL for 90 minutes; RADIOLOGY: MD to order MUGA Scan or ECHO-left ejection fraction only as indicated.
Day 10 - Lab only, Cycle 4 – Planned for 9/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28 days; COURSE: 6
cycles or until disease progression.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 10 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 10/3/2017 through 10/30/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28 days; COURSE: 6
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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
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
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, 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)
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 11 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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.
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
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) 78 mg in dextrose 5 % 250 mL bag
78 mg (rounded from 78.4 mg = 40 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer FIRST dose as follows: start at 50 mL/hour for 15 Minutes: If tolerated increase to 100 mL/hour for 15 minutes: If
tolerated increase to final rate over 60 minutes. Subsequest doses may be administered over 60 minutes. Hypersensitivity reaction
to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 12 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
doxorubicin LIPOSOMAL for 90 minutes; RADIOLOGY: MD to order MUGA Scan or ECHO-left ejection fraction only as indicated.
Day 10 - Lab only, Cycle 5 – Planned for 10/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28 days; COURSE: 6
cycles or until disease progression.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 10/31/2017 through 11/27/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 10/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28 days; COURSE: 6
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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 13 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, 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.
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
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
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 14 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) 78 mg in dextrose 5 % 250 mL bag
78 mg (rounded from 78.4 mg = 40 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer FIRST dose as follows: start at 50 mL/hour for 15 Minutes: If tolerated increase to 100 mL/hour for 15 minutes: If
tolerated increase to final rate over 60 minutes. Subsequest doses may be administered over 60 minutes. Hypersensitivity reaction
to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
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), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
doxorubicin LIPOSOMAL for 90 minutes; RADIOLOGY: MD to order MUGA Scan or ECHO-left ejection fraction only as indicated.
Day 10 - Lab only, Cycle 6 – Planned for 11/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Sarcoma (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1; CYCLE LENGTH: 28 days; COURSE: 6
cycles or until disease progression.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:06:13 PM Page 15 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org