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IP XELOX + BEVACIZUMAB (EVERY 21 DAYS)	

Types:      ONCOLOGY TREATMENT
Synonyms:  XELOX, CAPECITABINE, CAB, OXALOPLATIN, ELOXATIN, XELODA, COLORECTAL, GI, GASTRO, BEV, AVAST, BEVACIZUMAB, ZIRABEV

Cycle 1	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Nursing Orders
  	TREATMENT CONDITIONS	Interval: Once	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
			Provider Communication
  	ONC PROVIDER COMMUNICATION 64	Interval: Once	Occurrences: --	Comments:	Verify Hep B panel status prior to cycle. Date *** of panel. Result positive/negative/pending/unknown:22867

The required components for the hepatitis B panel includes: Hepatitis B surface antigen (HBsAg), total hepatitis B core antibody (anti-HBc), and hepatitis B antibody (anti-HBs).
			Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --		☑	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: Once	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 5	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in Urinalysis.
			Nursing Orders
  	TREATMENT CONDITIONS 30	Interval: Once	Occurrences: --	Comments:	HOLD Bevacizumab and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg
			Nursing Orders
  	TREATMENT CONDITIONS 4	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000; 
o Total Bilirubin GREATER than 1.5; 
o ALT/AST GREATER than 3 times upper limit of normal.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Oxaliplatin.		  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Oxaliplatin.		  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.  Do NOT administer with Oxaliplatin.			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Give 30 minutes prior to cetuximab.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S	End: S 11:30 AM			☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	PRN	Start: S					Provider Communication
  	ONC PROVIDER COMMUNICATION 60	Interval: Once	Occurrences: --	Comments:	To substitute Alymsys for Avastin OR MVASI OR Zirabev OR  Vegzelma OR Avzivi
o Right click and select Add Orders;
o Scroll down to the desired medication and click the radio button.
			Chemotherapy
◉	bevacizumab-maly (ALYMSYS) 7.5 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 7.5 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BEVACIZUMAB-MALY 25 MG/ML INTRAVENOUS SOLUTION	Medications	7.5 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes			◯	bevacizumab-bvzr (ZIRABEV) 7.5 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 7.5 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION	Medications	7.5 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes			◯	bevacizumab-awwb (MVASI) 7.5 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 7.5 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION	Medications	7.5 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes			◯	bevacizumab (AVASTIN) 7.5 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 7.5 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION	Medications	7.5 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	OXALIplatin (ELOXATIN) 130 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 130 mg/m2	Route: intravenous	once over 120 Minutes for 1 dose			Offset: 1 Hours	Instructions:	Irritant - avoid extravasation. Flush line with D5W before and after oxaliplatin infusion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION	Medications	130 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes			  	capecitabine (XELODA) chemo tablet 850 mg/m2 (Treatment Plan)	Dose: 850 mg/m2	Route: oral	2 times daily for 28 doses			Offset: 2 Hours	Instructions:	Day 1-14. DO NOT CUT OR CRUSH TABLET HAZARDOUS Handle with care.			Nursing Orders
  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	Exposure to cold may exacerbate oxaliplatin-induced neuropathy (including pharyngolaryngeal dysesthesia). Encourage patient to keep blanket on their chest and/or throat during oxaliplatin infusion. Educate patient to avoid cold drinks/foods, ice chips or exposure to cold water or air for 7 days after oxaliplatin infusion.
		  	ONC NURSING COMMUNICATION 12	Interval: Once	Occurrences: --	Comments:	Assess and notify provider for persistent neuropathy (Grade 2).
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Nursing Orders
  	ONC NURSING COMMUNICATION 15	Interval: Once	Occurrences: --	Comments:	Verify that the patient has appropriate prescription for oral chemotherapy medication.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.