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

/clinical/cckm-tools/content/beacon-protocols/gu/name-110542-en.cckm

201612340

page

100

UWHC,UWMF,

Tools,

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

CSC GU ddMVAC CISPLATIN(14D:1)/DOXORUBICIN(14D:1)/METHOTREXATE(14D:1)/VINBLASTINE(14D:1) VER 12-2-16 (HL 6200)

CSC GU ddMVAC CISPLATIN(14D:1)/DOXORUBICIN(14D:1)/METHOTREXATE(14D:1)/VINBLASTINE(14D:1) VER 12-2-16 (HL 6200) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU ddMVAC CISPLATIN(14D:1)/DOXORUBICIN(14D:1)/METHOTREXATE(14D:1)/VINBLASTINE(14D:1) VER: 12-2-
16 – Properties
Pre-Cycle – 11/25/2016 through 12/1/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder Cancer (Neoadjuvant); THERAPY: methotrexate 30 mg/m2 IV Day 1, vinBLAStine 3 mg/m2 IV Day 1,
doxorubicin 30 mg/m2 IV Day 1, CISplatin 70 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 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
ELECTROLYTES
Expected-S Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S Approximate, Expires-S+397, Routine
BUN
Expected-S Approximate, Expires-S+397, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
CALCIUM
Expected-S Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, 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 Day 2 and Day 3 of each cycle following chemotherapy., 80 mg, Disp-2 cap, R-3, 1 X
DAILY starting S
dexamethasone (DECADRON) 4 MG tab
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Zztestonc,Jeff J [2507481]
12/2/2016 8:07:58 AM Page 1 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Take 2 tabs by mouth one time daily. Take for 3 days on Day 2, 3, and 4 following chemotherapy., 8 mg, Disp-12 tab, R-1, 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
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
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
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 – 12/2/2016 through 12/15/2016 (14 days), Planned
Day 1, Cycle 1 – Planned for 12/2/2016
Treatment Plan Information
Reference Information (1)
UROTHELIAL CANCER: Plimack ER, et al. J Clin Oncol 2014;32(18):1895-1901.
Reference Information (2)
BLADDER CANCER: Choueiri TK, et al. J Clin Oncol 2014;32(18):1889-94.
Reference Information (3)
UROTHELIAL CANCER: Sternberg CN, et al. J Clin Oncol 2001;19(10):2638-46.
Treatment Plan Summary
DISEASE: Urothelial/Bladder Cancer (Neoadjuvant); THERAPY: methotrexate 30 mg/m2 IV Day 1, vinBLAStine 3 mg/m2 IV Day 1,
doxorubicin 30 mg/m2 IV Day 1, CISplatin 70 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 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.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
12/2/2016 8:07:58 AM Page 2 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@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% with KCl 20 mEq/L IV BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration.* Infuse 1000 mL thoughout treatment. Rate: 250-500 mL/hr.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
methotrexate PF (TREXALL) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV push rate 10 mg/minute.
vinBLAStine (VELBAN) 5.9 mg in sodium chloride 0.9 % 25 mL bag
5.9 mg (rounded from 5.88 mg = 3 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 5 minutes.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
CISplatin (PLATINOL) 137 mg in sodium chloride 0.9 % 1,000 mL bag
137 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Follow-Up
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: methotrexate,vinBLAStine, doxorubicin, and CISplatin for 120 minutes.
Cycle 2 – 12/16/2016 through 12/29/2016 (14 days), Planned
Day 1, Cycle 2 – Planned for 12/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder Cancer (Neoadjuvant); THERAPY: methotrexate 30 mg/m2 IV Day 1, vinBLAStine 3 mg/m2 IV Day 1,
doxorubicin 30 mg/m2 IV Day 1, CISplatin 70 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 cycles.
Consent
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Zztestonc,Jeff J [2507481]
12/2/2016 8:07:58 AM Page 3 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
12/2/2016 8:07:58 AM Page 4 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@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% with KCl 20 mEq/L IV BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration.* Infuse 1000 mL thoughout treatment. Rate: 250-500 mL/hr.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
methotrexate PF (TREXALL) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV push rate 10 mg/minute.
vinBLAStine (VELBAN) 5.9 mg in sodium chloride 0.9 % 25 mL bag
5.9 mg (rounded from 5.88 mg = 3 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 5 minutes.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
CISplatin (PLATINOL) 137 mg in sodium chloride 0.9 % 1,000 mL bag
137 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Follow-Up
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: methotrexate,vinBLAStine, doxorubicin, and CISplatin for 120 minutes.
Cycle 3 – 12/30/2016 through 1/12/2017 (14 days), Planned
Day 1, Cycle 3 – Planned for 12/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder Cancer (Neoadjuvant); THERAPY: methotrexate 30 mg/m2 IV Day 1, vinBLAStine 3 mg/m2 IV Day 1,
doxorubicin 30 mg/m2 IV Day 1, CISplatin 70 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 cycles.
Consent
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Zztestonc,Jeff J [2507481]
12/2/2016 8:07:58 AM Page 5 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
12/2/2016 8:07:58 AM Page 6 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@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% with KCl 20 mEq/L IV BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration.* Infuse 1000 mL thoughout treatment. Rate: 250-500 mL/hr.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
methotrexate PF (TREXALL) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV push rate 10 mg/minute.
vinBLAStine (VELBAN) 5.9 mg in sodium chloride 0.9 % 25 mL bag
5.9 mg (rounded from 5.88 mg = 3 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 5 minutes.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
CISplatin (PLATINOL) 137 mg in sodium chloride 0.9 % 1,000 mL bag
137 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Follow-Up
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: methotrexate,vinBLAStine, doxorubicin, and CISplatin for 120 minutes.
Cycle 4 – 1/13/2017 through 1/26/2017 (14 days), Planned
Day 1, Cycle 4 – Planned for 1/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder Cancer (Neoadjuvant); THERAPY: methotrexate 30 mg/m2 IV Day 1, vinBLAStine 3 mg/m2 IV Day 1,
doxorubicin 30 mg/m2 IV Day 1, CISplatin 70 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 cycles.
Consent
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Zztestonc,Jeff J [2507481]
12/2/2016 8:07:58 AM Page 7 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
12/2/2016 8:07:58 AM Page 8 of 9
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@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% with KCl 20 mEq/L IV BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration.* Infuse 1000 mL thoughout treatment. Rate: 250-500 mL/hr.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
methotrexate PF (TREXALL) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV push rate 10 mg/minute.
vinBLAStine (VELBAN) 5.9 mg in sodium chloride 0.9 % 25 mL bag
5.9 mg (rounded from 5.88 mg = 3 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 5 minutes.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
CISplatin (PLATINOL) 137 mg in sodium chloride 0.9 % 1,000 mL bag
137 mg (rounded from 137.2 mg = 70 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider.
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Zztestonc,Jeff J [2507481]
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org