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CSC GU Concurrent XRT Cisplatin(28D:1-5) Fluorouracil(28D:1-5) VER 12-1-16 (HL 3256)

CSC GU Concurrent XRT Cisplatin(28D:1-5) Fluorouracil(28D:1-5) VER 12-1-16 (HL 3256) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU CONCURRENT XRT CISPLATIN(28D:1-5)/FLUOROURACIL(28D:1-5) VER: 12-1-16 (HL 3256) – 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: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a continuous infusion IV
over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Take Home Medications
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
dexamethasone (DECADRON) 4 MG tab
Take 2 tablets by mouth on Day 6, 7, and 8, Disp-12 tab, R-0, starting S, Local Printer
Cycle 1 – 6/15/2017 through 7/12/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 6/15/2017
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Zztestonc,Jeff J [2507481]
6/15/2017 7:50:31 AM Page 1 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
BLADDER/UROTHELIAL/PENILE CANCER: Weiss C et al., Int. J. Radiat. Oncol. Biol. Phys.2007; 68(4):1072-80.
Treatment Plan Summary
DISEASE: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a continuous infusion IV
over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
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 and resulted: WBC, ANC, Platelets, Creatinine, Magnesium, Potassium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal or Magnesium below lower limits of normal or Potassium outside of normal range.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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 % 1,000 mL with potassium chloride 20 mEq infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* 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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:50:31 AM Page 2 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) 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.
fluorouracil (ADRUCIL) home infusion bag 1,176 mg
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Five Day Infusion: Fluorouracil Dose = 600 mg/m2/DAY administered as a single continuous infusion IV over 120 hours. (Total dose
= 3000 mg/m2 IV over 5 days)
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
MULTIPLE DAY FOLLOW-UP (1)
DAY 2 AND 3 FOLLOW-UP: CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 120 minutes.
DAY 4 FOLLOW-UP
LABS: Potassium, Magnesium, Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 120 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 120 minutes.
DAY 6 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and fluorouracil for 150 minutes.
Day 2, Cycle 1 – Planned for 6/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a continuous infusion IV
over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
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
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
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]
6/15/2017 7:50:31 AM Page 3 of 15
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 % 1,000 mL with potassium chloride 20 mEq infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* 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.
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 6/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a continuous infusion IV
over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
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
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
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]
6/15/2017 7:50:31 AM Page 4 of 15
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 % 1,000 mL with potassium chloride 20 mEq infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* 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.
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 6/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a continuous infusion IV
over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:50:31 AM Page 5 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Creatinine, Magnesium, Potassium.
Treatment Parameters
Hold and notify authorizing prescriber for Creatinine greater than upper limits of normal or Magnesium below lower limits of normal
or Potassium outside of normal range.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
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 % 1,000 mL with potassium chloride 20 mEq infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* 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.
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 6/19/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/15/2017 7:50:31 AM Page 6 of 15
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: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a
continuous infusion IV over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home
infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
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
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
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 % 1,000 mL with potassium chloride 20 mEq infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* 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.
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 6 (Pump Disconnect), Cycle 1 – Planned for 6/20/2017
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Zztestonc,Jeff J [2507481]
6/15/2017 7:50:31 AM Page 7 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a continuous infusion IV
over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
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.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 120-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/13/2017 through 8/9/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 7/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a continuous infusion IV
over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
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+24 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+24 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+24 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:50:31 AM Page 8 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

GLUCOSE
Expected-S+24 Approximate, Expires-S+365, Routine
BUN
Expected-S+24 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+24 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+24 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+24 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+24 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+24 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Magnesium, Potassium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal or Magnesium below lower limits of normal or Potassium outside of normal range.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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 % 1,000 mL with potassium chloride 20 mEq infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* 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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:50:31 AM Page 9 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 12 mg
12 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.
fluorouracil (ADRUCIL) home infusion bag 1,176 mg
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Five Day Infusion: Fluorouracil Dose = 600 mg/m2/DAY administered as a single continuous infusion IV over 120 hours. (Total dose
= 3000 mg/m2 IV over 5 days)
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
MULTIPLE DAY FOLLOW-UP (1)
DAY 2 AND 3 FOLLOW-UP: CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 120 minutes.
DAY 4 FOLLOW-UP
LABS: Potassium, Magnesium, Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 120 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 120 minutes.
DAY 6 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and fluorouracil for 150 minutes.
Day 2, Cycle 2 – Planned for 7/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a continuous infusion IV
over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
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
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:50:31 AM Page 10 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* 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.
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 7/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a continuous infusion IV
over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
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
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:50:31 AM Page 11 of 15
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 % 1,000 mL with potassium chloride 20 mEq infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* 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.
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 7/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a continuous infusion IV
over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:50:31 AM Page 12 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Creatinine, Magnesium, Potassium.
Treatment Parameters
Hold and notify authorizing prescriber for Creatinine greater than upper limits of normal or Magnesium below lower limits of normal
or Potassium outside of normal range.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
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 % 1,000 mL with potassium chloride 20 mEq infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* 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.
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 7/17/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/15/2017 7:50:31 AM Page 13 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a continuous infusion IV
over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
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
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
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 % 1,000 mL with potassium chloride 20 mEq infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* 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.
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 6 (Pump Disconnect), Cycle 2 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/15/2017 7:50:31 AM Page 14 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Urothelial/Bladder/Penile Cancer (Advanced);
THERAPY: CISplatin 20 mg/m2 IV Day 1 through 5; fluorouracil dose = 600 mg/m2/DAY administered as a
continuous infusion IV over 120 hours on Day 1 through 5 (Total dose = 3000 mg/m2 over 120 hours per home
infusion):
CYCLE LENGTH: 28 days;
COURSE: duration of radiation treatments.
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.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 120-hour fluorouracil infusion.
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 7:50:31 AM Page 15 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org