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

/clinical/cckm-tools/content/beacon-protocols/brain/name-96558-en.cckm

201711317

page

100

UWHC,UWMF,

Tools,

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

CSC Brain Cisplatin(42D:1)/Cyclophosphamide(42D:22,23) VER 9-13-17 (HL 1082)

CSC Brain Cisplatin(42D:1)/Cyclophosphamide(42D:22,23) VER 9-13-17 (HL 1082) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Brain


CSC BRAIN CISPLATIN(42D:1)/CYCLOPHOSPHAMIDE(42D:22,23) VER: 9-13-17 –  Properties
Pre-Cycle –  11/6/2017 through 11/12/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 11/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take on Day 2 and 3., 80 mg, Disp-2 cap, R-7, 1 X DAILY starting S
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
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 2, 3 and 4 and Day 24, 25 and 26., 8 mg, Disp-48 tab, R-1, 1 X
DAILY starting S
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after
nadir., 300 mcg, Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 1 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after
nadir., 480 mcg, Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 –  11/13/2017 through 12/24/2017 (42 days), Planned
Day 1, Cycle 1 –  Planned for 11/13/2017
Treatment Plan Information
Reference Information (1)
MEDULLOBLASTOMA: Packer R, et al. J Clin Oncol 2006;24(25):4202-8.
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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, Creatinine, Electrolytes, Magnesium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL or Creatinine
greater than 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Measure urine output. Notify physician if urine output less than 400 mL prior to discharge.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 2 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours prior to CISplatin.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
For 60 to 120 minutes.
Follow-Up
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Potassium, Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT:
cyclophosphamide for 90 minutes
DAY 23 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide for 90 minutes
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if drawn locally),
Electrolytes, BUN, Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 180 minutes
Day 22, Cycle 1 –  Planned for 12/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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
POTASSIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 3 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
Patient Instructions(2)
Teach patient how to self-administer a subcutaneous injection.
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 throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 4 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 23, Cycle 1 –  Planned for 12/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
Patient Instructions(2)
Review subcutaneous injection self-administration teaching with patient.
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 throughout treatment.
Pre-Medications
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 5 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 29, Cycle 1 –  Planned for 12/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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+6 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+6 Approximate, Expires: S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  12/25/2017 through 2/4/2018 (42 days), Planned
Day 1, Cycle 2 –  Planned for 12/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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+20 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 6 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Expected: S+20 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL or Creatinine
greater than 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Measure urine output. Notify physician if urine output less than 400 mL prior to discharge.
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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours prior to CISplatin.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 7 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
For 60 to 120 minutes.
Follow-Up
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Potassium, Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT:
cyclophosphamide for 90 minutes
DAY 23 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide for 90 minutes
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if drawn locally),
Electrolytes, BUN, Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 180 minutes
Day 22, Cycle 2 –  Planned for 1/15/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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
POTASSIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 8 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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 throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 23, Cycle 2 –  Planned for 1/16/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 9 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Patient Instructions(2)
Review subcutaneous injection self-administration teaching with patient.
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 throughout treatment.
Pre-Medications
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 29, Cycle 2 –  Planned for 1/22/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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+6 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 10 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Expected: S+6 Approximate, Expires: S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  2/5/2018 through 3/18/2018 (42 days), Planned
Day 1, Cycle 3 –  Planned for 2/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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+20 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL or Creatinine
greater than 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 11 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

EVERY 4 HOURS Starting when released Until Specified
Measure urine output. Notify physician if urine output less than 400 mL prior to discharge.
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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours prior to CISplatin.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
For 60 to 120 minutes.
Follow-Up
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Potassium, Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT:
cyclophosphamide for 90 minutes
DAY 23 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide for 90 minutes
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if drawn locally),
Electrolytes, BUN, Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 180 minutes
Day 22, Cycle 3 –  Planned for 2/26/2018
Treatment Plan Information
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 12 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1,
cyclophosphamide 1000 mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42
days; COURSE: 8 cycles
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
POTASSIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
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 throughout treatment.
Pre-Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 13 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 23, Cycle 3 –  Planned for 2/27/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
Patient Instructions(2)
Review subcutaneous injection self-administration teaching with patient.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 14 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 29, Cycle 3 –  Planned for 3/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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+6 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+6 Approximate, Expires: S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  3/19/2018 through 4/29/2018 (42 days), Planned
Day 1, Cycle 4 –  Planned for 3/19/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
Consent
Verify Consent
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 15 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@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+20 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL or Creatinine
greater than 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Measure urine output. Notify physician if urine output less than 400 mL prior to discharge.
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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours prior to CISplatin.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 16 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
For 60 to 120 minutes.
Follow-Up
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Potassium, Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT:
cyclophosphamide for 90 minutes
DAY 23 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide for 90 minutes
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if drawn locally),
Electrolytes, BUN, Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 180 minutes
Day 22, Cycle 4 –  Planned for 4/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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
POTASSIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 17 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Expected: S+21 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
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 throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 23, Cycle 4 –  Planned for 4/10/2018
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 18 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
Patient Instructions(2)
Review subcutaneous injection self-administration teaching with patient.
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 throughout treatment.
Pre-Medications
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 29, Cycle 4 –  Planned for 4/16/2018
Treatment Plan Information
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 19 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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+6 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+6 Approximate, Expires: S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  4/30/2018 through 6/10/2018 (42 days), Planned
Day 1, Cycle 5 –  Planned for 4/30/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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+20 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
CREATININE
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 20 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Expected: S+20 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL or Creatinine
greater than 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Measure urine output. Notify physician if urine output less than 400 mL prior to discharge.
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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours prior to CISplatin.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
For 60 to 120 minutes.
Follow-Up
DAY 22 FOLLOW-UP
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 21 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if done locally), Potassium, Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT:
cyclophosphamide for 90 minutes
DAY 23 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide for 90 minutes
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if drawn locally),
Electrolytes, BUN, Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 180 minutes
Day 22, Cycle 5 –  Planned for 5/21/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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
POTASSIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 22 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@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 throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 23, Cycle 5 –  Planned for 5/22/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
Patient Instructions(2)
Review subcutaneous injection self-administration teaching with patient.
Flush Venous Access Device per Guidelines
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 23 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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 throughout treatment.
Pre-Medications
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 29, Cycle 5 –  Planned for 5/28/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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+6 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+6 Approximate, Expires: S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 24 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  6/11/2018 through 7/22/2018 (42 days), Planned
Day 1, Cycle 6 –  Planned for 6/11/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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+20 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
ELECTROLYTES
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+20 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL or Creatinine
greater than 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Measure urine output. Notify physician if urine output less than 400 mL prior to discharge.
Flush Venous Access Device per Guidelines
Order details
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 25 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours prior to CISplatin.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
For 60 to 120 minutes.
Follow-Up
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Potassium, Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT:
cyclophosphamide for 90 minutes
DAY 23 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide for 90 minutes
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if drawn locally),
Electrolytes, BUN, Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 180 minutes
Day 22, Cycle 6 –  Planned for 7/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
IV Access
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 26 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@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+21 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
POTASSIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
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 throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 27 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 23, Cycle 6 –  Planned for 7/3/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
Patient Instructions(2)
Review subcutaneous injection self-administration teaching with patient.
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 throughout treatment.
Pre-Medications
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 28 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Medications
cyclophosphamide (CYTOXAN) 1,000 mg/m2 in sodium chloride 0.9 % 250 mL bag
1,000 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 29, Cycle 6 –  Planned for 7/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Medulloblastoma (Adjuvant or Advanced); THERAPY: CISplatin 75 mg/m2 IV Day 1, cyclophosphamide 1000
mg/m2 IV Day 22 and 23; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 42 days; COURSE: 8 cycles
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+6 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+6 Approximate, Expires: S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/13/2017 10:36:08 AM Page 29 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org