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201708223

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

CSC GI Concurrent XRT Carboplatin (35D:1,8,15,22,29) Paclitaxel (35D:1,8,15,22,29) VER 8-15-17 (HL 4835)

CSC GI Concurrent XRT Carboplatin (35D:1,8,15,22,29) Paclitaxel (35D:1,8,15,22,29) VER 8-15-17 (HL 4835) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI CONCURRENT XRT CARBOPLATIN(35D:1,8,15,22,29)/PACLITAXEL(35D:1,8,15,22,29) VER: 8-15-
17 –  Properties
Pre-Cycle –  8/3/2017 through 8/9/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal, Gastric, Gastroesophageal Junction Cancer (Neo-Adjuvant); THERAPY: PACLItaxel 50 mg/m2 IV
Days 1, 8, 15, 22, and 29, CARBOplatin AUC 2 IV Days 1, 8, 15, 22, and 29 concurrent with radiotherapy; CYCLE LENGTH:
35 days; COURSE: 1 cycle.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
CALCIUM
Expected: S Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth 2 times daily. Take 12 hours and 6 hours prior to PACLItaxel administration., 20 mg, Disp-50 tab,
R-0, 2 X DAILY starting S, Local Printer
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
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
Cycle 1 –  8/10/2017 through 9/13/2017 (35 days), Planned
Day 1, Cycle 1 –  Planned for 8/10/2017
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Zztestonc,Jeff J [2507481]
8/10/2017 8:37:51 AM Page 1 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
ESOPHAGEAL, GASTRIC, GASTROESOPHAGEAL JUNCTION CANCER: van Hagen, et al. N Engl J Med. 2012;366(22):2074-
84.
Treatment Plan Summary
DISEASE: Esophageal, Gastric, Gastroesophageal Junction Cancer (Neo-Adjuvant); THERAPY: PACLItaxel 50 mg/m2 IV
Days 1, 8, 15, 22, and 29, CARBOplatin AUC 2 IV Days 1, 8, 15, 22, and 29 concurrent with radiotherapy; CYCLE LENGTH:
35 days; COURSE: 1 cycle.
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 with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:37:51 AM Page 2 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 98 mg in dextrose 5 % 250 mL non-PVC bag
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Infuse over 60 minutes (see titration instructions below). Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration. Hypersensitivity Risk - See Emergency Meds.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 250 mL bag
(Target AUC = 2), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk.  See emergency medications. For first and second dose, patient
should be treated in a location to optimize emergency care.
Follow-Up
DAY 8 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
8/10/2017 8:37:51 AM Page 3 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

LABS: CBC with DIFF, Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: PACLitaxel and CARBOplatin
for 120 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: PACLitaxel and CARBOplatin for 120 minutes.
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: PACLItaxel and CARBOplatin for 120 minutes.
DAY 29 FOLLOW-UP
LABS: CBC with DIFF, Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel and CARBOplatin for 120 minutes.
Day 8, Cycle 1 –  Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal, Gastric, Gastroesophageal Junction Cancer (Neo-Adjuvant); THERAPY: PACLItaxel 50 mg/m2 IV
Days 1, 8, 15, 22, and 29, CARBOplatin AUC 2 IV Days 1, 8, 15, 22, and 29 concurrent with radiotherapy; CYCLE LENGTH:
35 days; COURSE: 1 cycle.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
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Zztestonc,Jeff J [2507481]
8/10/2017 8:37:51 AM Page 4 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 98 mg in dextrose 5 % 250 mL non-PVC bag
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Infuse over 60 minutes (see titration instructions below). Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration. Hypersensitivity Risk - See Emergency Meds.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
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Zztestonc,Jeff J [2507481]
8/10/2017 8:37:51 AM Page 5 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 250 mL bag
(Target AUC = 2), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk.  See emergency medications. For first and second dose, patient
should be treated in a location to optimize emergency care.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 –  Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal, Gastric, Gastroesophageal Junction Cancer (Neo-Adjuvant); THERAPY: PACLItaxel 50 mg/m2 IV
Days 1, 8, 15, 22, and 29, CARBOplatin AUC 2 IV Days 1, 8, 15, 22, and 29 concurrent with radiotherapy; CYCLE LENGTH:
35 days; COURSE: 1 cycle.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
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Zztestonc,Jeff J [2507481]
8/10/2017 8:37:51 AM Page 6 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 98 mg in dextrose 5 % 250 mL non-PVC bag
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Infuse over 60 minutes (see titration instructions below). Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration. Hypersensitivity Risk - See Emergency Meds.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
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Zztestonc,Jeff J [2507481]
8/10/2017 8:37:51 AM Page 7 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 250 mL bag
(Target AUC = 2), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk.  See emergency medications. For first and second dose, patient
should be treated in a location to optimize emergency care.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 –  Planned for 8/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal, Gastric, Gastroesophageal Junction Cancer (Neo-Adjuvant); THERAPY: PACLItaxel 50 mg/m2 IV
Days 1, 8, 15, 22, and 29, CARBOplatin AUC 2 IV Days 1, 8, 15, 22, and 29 concurrent with radiotherapy; CYCLE LENGTH:
35 days; COURSE: 1 cycle.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
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Zztestonc,Jeff J [2507481]
8/10/2017 8:37:51 AM Page 8 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 98 mg in dextrose 5 % 250 mL non-PVC bag
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Infuse over 60 minutes (see titration instructions below). Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration. Hypersensitivity Risk - See Emergency Meds.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
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Zztestonc,Jeff J [2507481]
8/10/2017 8:37:51 AM Page 9 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 250 mL bag
(Target AUC = 2), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk.  See emergency medications. For first and second dose, patient
should be treated in a location to optimize emergency care.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 1 –  Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal, Gastric, Gastroesophageal Junction Cancer (Neo-Adjuvant); THERAPY: PACLItaxel 50 mg/m2 IV
Days 1, 8, 15, 22, and 29, CARBOplatin AUC 2 IV Days 1, 8, 15, 22, and 29 concurrent with radiotherapy; CYCLE LENGTH:
35 days; COURSE: 1 cycle.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
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Zztestonc,Jeff J [2507481]
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 98 mg in dextrose 5 % 250 mL non-PVC bag
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Infuse over 60 minutes (see titration instructions below). Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration. Hypersensitivity Risk - See Emergency Meds.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
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Zztestonc,Jeff J [2507481]
8/10/2017 8:37:51 AM Page 11 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 250 mL bag
(Target AUC = 2), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk.  See emergency medications. For first and second dose, patient
should be treated in a location to optimize emergency care.
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]
8/10/2017 8:37:51 AM Page 12 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org