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201706166

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CSC GU Cisplatin(21D:1) Etoposide(21:D1,2,3) VER 12-1-16 (HL 708)

CSC GU Cisplatin(21D:1) Etoposide(21:D1,2,3) VER 12-1-16 (HL 708) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU CISPLATIN(21D1)ETOPOSIDE(21D1,2,3) VER 12-1-16 (HL 708) – Properties
Pre-Cycle – 6/8/2017 through 6/14/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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
ELECTROLYTES
Expected-S Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S Approximate, Expires-S+397, Routine
BUN
Expected-S Approximate, Expires-S+397, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
CALCIUM
Expected-S Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
PSA TOTAL, DIAGNOSTIC
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 1 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Take 2 tabs by mouth one time daily. Take 2 tablets by mouth once on Day 4 of each cycle., 8 mg, Disp-12 tab, R-0, 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 – 6/15/2017 through 7/5/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Reference Information (1)
PROSTATE CANCER (NEUROENDROCRINE FEATURES/EXTRAPULMONARY SMALL CELL TUMOR): Loehrer PJ, et al. Semin
Oncol, 1988;15:2-8.
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 2 of 26
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 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.
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
Treatment Medications
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 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: etoposide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide for 120 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15 (if needed): LABS: AFP, HCG, LDH.
DAY 10 FOLLOW-UP
LABS:CBC, ANC (DIFF if done locally), Potassium, Magnesium.
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, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, PSA, AFP, HCG, LDH; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
Day 2, Cycle 1 – Planned for 6/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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]
6/15/2017 7:35:55 AM Page 3 of 26
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
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
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.
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 6/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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
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]
6/15/2017 7:35:55 AM Page 4 of 26
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 1 – Planned for 6/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+9 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/6/2017 through 7/26/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
Consent
Verify Consent
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 5 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
POTASSIUM
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
PSA TOTAL, DIAGNOSTIC
Expected-S 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
Measure Intake And Output
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 6 of 26
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
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
Treatment Medications
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 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: etoposide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide for 120 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15 (if needed): LABS: AFP, HCG, LDH.
DAY 10 FOLLOW-UP
LABS:CBC, ANC (DIFF if done locally), Potassium, Magnesium.
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, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, PSA, AFP, HCG, LDH; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 7 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Day 2, Cycle 2 – Planned for 7/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
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.
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 7/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 8 of 26
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 2 – Planned for 7/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+9 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+9 Approximate, Expires-S+365, Routine
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]
6/15/2017 7:35:55 AM Page 9 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Cycle 3 – 7/27/2017 through 8/16/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
POTASSIUM
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
PSA TOTAL, DIAGNOSTIC
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 10 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S 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
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.
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
Treatment Medications
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 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: etoposide for 120 minutes.
DAY 3 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 11 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CHEMOTHERAPY ROOM APPOINTMENT: etoposide for 120 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15 (if needed): LABS: AFP, HCG, LDH.
DAY 10 FOLLOW-UP
LABS:CBC, ANC (DIFF if done locally), Potassium, Magnesium.
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, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, PSA, AFP, HCG, LDH; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
Day 2, Cycle 3 – Planned for 7/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
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.
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 7/29/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 12 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY:
CISplatin 75 mg/m2 IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6
cycles or until disease progression.
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
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 3 – Planned for 8/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 13 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+9 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+9 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 8/17/2017 through 9/6/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 14 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ALT/SGPT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
POTASSIUM
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
PSA TOTAL, DIAGNOSTIC
Expected-S 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
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.
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
Treatment Medications
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 15 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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: etoposide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide for 120 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15 (if needed): LABS: AFP, HCG, LDH.
DAY 10 FOLLOW-UP
LABS:CBC, ANC (DIFF if done locally), Potassium, Magnesium.
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, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, PSA, AFP, HCG, LDH; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
Day 2, Cycle 4 – Planned for 8/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 16 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Medications
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.
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 8/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 4 – Planned for 8/26/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 17 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+9 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 9/7/2017 through 9/27/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 18 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CALCIUM
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
POTASSIUM
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
PSA TOTAL, DIAGNOSTIC
Expected-S 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
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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 19 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
Treatment Medications
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 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: etoposide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide for 120 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15 (if needed): LABS: AFP, HCG, LDH.
DAY 10 FOLLOW-UP
LABS:CBC, ANC (DIFF if done locally), Potassium, Magnesium.
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, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, PSA, AFP, HCG, LDH; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
Day 2, Cycle 5 – Planned for 9/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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
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]
6/15/2017 7:35:55 AM Page 20 of 26
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 5 – Planned for 9/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 21 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 5 – Planned for 9/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+9 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 9/28/2017 through 10/18/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 22 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
POTASSIUM
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
PSA TOTAL, DIAGNOSTIC
Expected-S 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
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:35:55 AM Page 23 of 26
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 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.
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
Treatment Medications
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 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: etoposide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide for 120 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15 (if needed): LABS: AFP, HCG, LDH.
DAY 10 FOLLOW-UP
LABS:CBC, ANC (DIFF if done locally), Potassium, Magnesium.
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, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, PSA, AFP, HCG, LDH; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and etoposide for 180 minutes.
Day 2, Cycle 6 – Planned for 9/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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]
6/15/2017 7:35:55 AM Page 24 of 26
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
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 6 – Planned for 9/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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
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]
6/15/2017 7:35:55 AM Page 25 of 26
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
Treatment Medications
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 6 – Planned for 10/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced/Neuroendocrine featues/extrapulmonary small cell tumor); THERAPY: CISplatin 75 mg/m2
IV Day 1, etoposide 100 mg/m2 IV Day 1, 2, and 3; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+9 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+9 Approximate, Expires-S+365, Routine
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]
6/15/2017 7:35:55 AM Page 26 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org