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CSC GU Bleomycin(21D:1,8,15) Cisplatin(21D:1-5) Etoposide(21D:1-5) VER 12-1-16 (HL 953)

CSC GU Bleomycin(21D:1,8,15) Cisplatin(21D:1-5) Etoposide(21D:1-5) VER 12-1-16 (HL 953) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU BLEOMYCIN(21D1,8,15)CISPLATIN(21D1-5)ETOPOSIDE(21D1-5) VER 12-1-16 (HL 953) – Properties
Pre-Cycle – 6/7/2017 through 6/13/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 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
POTASSIUM
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S Approximate, Expires-S+365, Normal, Routine
HCG, QUANTITATIVE
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 6, 7 and 8., 8 mg, Disp-24 tab, R-1, 1 X DAILY 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 – 6/14/2017 through 7/4/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/14/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 1 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Reference Information (1)
TESTICULAR/GERM CELL CANCER: Bosi GJ, et al. J Clin Oncol 1988;6:1231-8.
Reference Information (2)
TESTICULAR/GERM CELL CANCER: Williams SD, et al. N Engl J Med 1987;316:1435-40.
Reference Information (3)
TESTICULAR/GERM CELL CANCER: Culine S, et al. Proc Am Soc Clin Oncol 2003;abstract 1536.
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 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.
Additional Labs (delete all that do not apply)
AFP, TUMOR MARKER, SERUM
Expected-S+7, Expires-S+14, Normal, Routine
DAY 8: MD to delete if not needed.
AFP, TUMOR MARKER, SERUM
Expected-S+14, Expires-S+14, Normal, Routine
DAY 15: MD to delete if not needed.
HCG, QUANTITATIVE
Expected-S+7, Expires-S+14, Normal, Routine
DAY 8: MD to delete if not needed.
HCG, QUANTITATIVE
Expected-S+14, Expires-S+14, Normal, Routine
DAY 15: MD to delete if not needed.
LD, TOTAL
Expected-S+7, Expires-S+14, Normal, Routine
DAY 8: MD to delete if not needed.
LD, TOTAL
Expected-S+14, Expires-S+14, Normal, Routine
DAY 15: MD to delete if not needed.
Treatment Conditions
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
Measure Intake And Output
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 2 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bleomycin (BLENOXANE) 30 units in sodium chloride 0.9 % 100 mL bag
30 units, Intravenous, ONCE, 1 dose Starting when released
NOTE: FIXED DOSE
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 3 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
DAY 4 FOLLOW-UP
LABS: Magnesium, Potassium, Creatinine, Phosphate. CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180
minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15: LABS: CBC, ANC (DIFF if to be done locally); LABS (if needed): Alpha-Fetoprotein, Quantitative HCG, Total LD;
CHEMOTHERAPY ROOM APPOINTMENT: bleomycin for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM APPOINTMENT: bleomycin,
CISplatin and etoposide for 200 minutes.
Day 2, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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.
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 4 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 – Planned for 6/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 5 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 1 – Planned for 6/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Magnesium, Potassium
Treatment Parameters
Hold treatment and notify authorizing prescriber for any pre-lab results not within normal limits.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 6 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 – Planned for 6/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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.
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 7 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 – Planned for 6/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 8 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
Check patient for mouth sores prior to administration of chemotherapy.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 9 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

bleomycin (BLENOXANE) 30 units in sodium chloride 0.9 % 100 mL bag
30 units, Intravenous, ONCE, 1 dose Starting when released
NOTE: FIXED DOSE
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 6/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
Check patient for mouth sores prior to administration of chemotherapy.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 10 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bleomycin (BLENOXANE) 30 units in sodium chloride 0.9 % 100 mL bag
30 units, Intravenous, ONCE, 1 dose Starting when released
NOTE: FIXED DOSE
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/5/2017 through 7/25/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 11 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
HCG, QUANTITATIVE
Expected-S+7 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+7 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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
dexamethasone (DECADRON) tab 12 mg
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 12 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bleomycin (BLENOXANE) 30 units in sodium chloride 0.9 % 100 mL bag
30 units, Intravenous, ONCE, 1 dose Starting when released
NOTE: FIXED DOSE
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
DAY 4 FOLLOW-UP
LABS: Magnesium, Potassium, Creatinine, Phosphate. CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180
minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15: LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bleomycin for 60
minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM APPOINTMENT: bleomycin,
CISplatin and etoposide for 200 minutes.
Day 2, Cycle 2 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 13 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 2 – Planned for 7/7/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 14 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 2 – Planned for 7/8/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 15 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Magnesium, Potassium
Treatment Parameters
Hold treatment and notify authorizing prescriber for any pre-lab results not within normal limits.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 16 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 2 – Planned for 7/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 17 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 2 – Planned for 7/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
Check patient for mouth sores prior to administration of chemotherapy.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 18 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bleomycin (BLENOXANE) 30 units in sodium chloride 0.9 % 100 mL bag
30 units, Intravenous, ONCE, 1 dose Starting when released
NOTE: FIXED DOSE
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 7/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 19 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
Check patient for mouth sores prior to administration of chemotherapy.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bleomycin (BLENOXANE) 30 units in sodium chloride 0.9 % 100 mL bag
30 units, Intravenous, ONCE, 1 dose Starting when released
NOTE: FIXED DOSE
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 20 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 7/26/2017 through 8/15/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
HCG, QUANTITATIVE
Expected-S+7 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+7 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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
Flush Venous Access Device per Guidelines
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 21 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bleomycin (BLENOXANE) 30 units in sodium chloride 0.9 % 100 mL bag
30 units, Intravenous, ONCE, 1 dose Starting when released
NOTE: FIXED DOSE
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 22 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
DAY 4 FOLLOW-UP
LABS: Magnesium, Potassium, Creatinine, Phosphate. CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180
minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15: LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bleomycin for 60
minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM APPOINTMENT: bleomycin,
CISplatin and etoposide for 200 minutes.
Day 2, Cycle 3 – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 23 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 3 – Planned for 7/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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.
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 24 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Medications
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 3 – Planned for 7/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Magnesium, Potassium
Treatment Parameters
Hold treatment and notify authorizing prescriber for any pre-lab results not within normal limits.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 25 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 3 – Planned for 7/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
Measure Intake And Output
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 26 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 3 – Planned for 8/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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+3 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 27 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
Check patient for mouth sores prior to administration of chemotherapy.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bleomycin (BLENOXANE) 30 units in sodium chloride 0.9 % 100 mL bag
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 28 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

30 units, Intravenous, ONCE, 1 dose Starting when released
NOTE: FIXED DOSE
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 – Planned for 8/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
Check patient for mouth sores prior to administration of chemotherapy.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 29 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bleomycin (BLENOXANE) 30 units in sodium chloride 0.9 % 100 mL bag
30 units, Intravenous, ONCE, 1 dose Starting when released
NOTE: FIXED DOSE
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 8/16/2017 through 9/5/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 30 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
HCG, QUANTITATIVE
Expected-S+7 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+7 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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 31 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bleomycin (BLENOXANE) 30 units in sodium chloride 0.9 % 100 mL bag
30 units, Intravenous, ONCE, 1 dose Starting when released
NOTE: FIXED DOSE
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
DAY 4 FOLLOW-UP
LABS: Magnesium, Potassium, Creatinine, Phosphate. CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180
minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bleomycin for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bleomycin for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider.
Day 2, Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 cycles.
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 32 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 – Planned for 8/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 cycles.
IV Access
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 33 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 4 – Planned for 8/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 cycles.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 34 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Magnesium, Potassium
Treatment Parameters
Hold treatment and notify authorizing prescriber for any pre-lab results not within normal limits.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 35 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 4 – Planned for 8/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
Conditional Orders
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 36 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 4 – Planned for 8/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
Check patient for mouth sores prior to administration of chemotherapy.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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.
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 37 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bleomycin (BLENOXANE) 30 units in sodium chloride 0.9 % 100 mL bag
30 units, Intravenous, ONCE, 1 dose Starting when released
NOTE: FIXED DOSE
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 – Planned for 8/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Adjuvant/Advanced);
THERAPY: bleomycin 30 units (FIXED DOSE) IV push Days 1, 8, and 15, CISplatin 20 mg/m2 IV Day 1 through 5, etoposide 100
mg/m2 IV Day 1 through 5; CYCLE LENGTH: 21 days; COURSE: 3 to 4 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Treatment Condition A
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 38 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Check patient for mouth sores prior to administration of chemotherapy.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bleomycin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient should be monitored for 30 minutes post first dose of bleomycin. See Emergency Medications.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to bleomycin.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bleomycin (BLENOXANE) 30 units in sodium chloride 0.9 % 100 mL bag
30 units, Intravenous, ONCE, 1 dose Starting when released
NOTE: FIXED DOSE
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/14/2017 4:19:20 PM Page 39 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org