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CSC GU Gemcitabine(21D:1,8) Oxaliplatin(21D:1) VER 12-1-16 (HL 715)

CSC GU Gemcitabine(21D:1,8) Oxaliplatin(21D:1) VER 12-1-16 (HL 715) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU GEMCITABINE(21D:1,8)/OXALIPLATIN(21D:1) VER: 12-1-16 (HL 715) – 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: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S Approximate, Expires-S+365, Normal, Routine
HCG, QUANTITATIVE
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy., 8 mg, Disp-24 tab, R-5, 1 X DAILY starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting (For nausea)., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS
PRN starting S
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)
TESTICULAR, GERM CELL CANCER: Kollmannsberger C, et al. J Clin Oncol 2004;22:108-14.
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 1 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Additional Labs (delete all that do not apply)
AFP, TUMOR MARKER, SERUM
Expected-S+7, Expires-S+14, Normal, Routine
DAY 8: MD to delete if not needed.
AFP, TUMOR MARKER, SERUM
Expected-S+14, Expires-S+14, Normal, Routine
DAY 15: MD to delete if not needed.
HCG, QUANTITATIVE
Expected-S+7, Expires-S+14, Normal, Routine
DAY 8: MD to delete if not needed.
HCG, QUANTITATIVE
Expected-S+14, Expires-S+14, Normal, Routine
DAY 15: MD to delete if not needed.
LD, TOTAL
Expected-S+7, Expires-S+14, Normal, Routine
DAY 8: MD to delete if not needed.
LD, TOTAL
Expected-S+14, Expires-S+14, Normal, Routine
DAY 15: MD to delete if not needed.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 2 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation. Allow for adequate flushing between gemcitabine
and oxaliplatin with Dextrose 5% in Water.
oxaliplatin (ELOXATIN) 255 mg in dextrose 5 % 250 mL bag
255 mg (rounded from 254.8 mg = 130 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity risk. See emergency medications. Administer over 120 minutes. Incompatible with Sodium Chloride. Allow adequate
flushing with Dextrose 5% in Water when necessary between chemotherapy treatment medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); LABS (if needed): Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY
ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); LABS (if needed): Alpha-Fetoprotein, Quantitative HCG, Total LD.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine
and oxaliplatin for 200 minutes.
Day 8, Cycle 1 – Planned for 6/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 3 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 6/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 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: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression
Consent
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 4 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
HCG, QUANTITATIVE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 5 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation. Allow for adequate flushing between gemcitabine
and oxaliplatin with Dextrose 5% in Water.
oxaliplatin (ELOXATIN) 255 mg in dextrose 5 % 250 mL bag
255 mg (rounded from 254.8 mg = 130 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity risk. See emergency medications. Administer over 120 minutes. Incompatible with Sodium Chloride. Allow adequate
flushing with Dextrose 5% in Water when necessary between chemotherapy treatment medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine
and oxaliplatin for 200 minutes.
Day 8, Cycle 2 – Planned for 7/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 6 of 20
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 2 – Planned for 7/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 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 3 – 7/27/2017 through 8/16/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/27/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 7 of 20
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: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
HCG, QUANTITATIVE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 8 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation. Allow for adequate flushing between gemcitabine
and oxaliplatin with Dextrose 5% in Water.
oxaliplatin (ELOXATIN) 255 mg in dextrose 5 % 250 mL bag
255 mg (rounded from 254.8 mg = 130 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity risk. See emergency medications. Administer over 120 minutes. Incompatible with Sodium Chloride. Allow adequate
flushing with Dextrose 5% in Water when necessary between chemotherapy treatment medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine
and oxaliplatin for 200 minutes.
Day 8, Cycle 3 – Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 9 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 – Planned for 8/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 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 7:57:26 AM Page 10 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
HCG, QUANTITATIVE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Flush Venous Access Device per Guidelines
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 11 of 20
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation. Allow for adequate flushing between gemcitabine
and oxaliplatin with Dextrose 5% in Water.
oxaliplatin (ELOXATIN) 255 mg in dextrose 5 % 250 mL bag
255 mg (rounded from 254.8 mg = 130 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity risk. See emergency medications. Administer over 120 minutes. Incompatible with Sodium Chloride. Allow adequate
flushing with Dextrose 5% in Water when necessary between chemotherapy treatment medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine
and oxaliplatin for 200 minutes.
Day 8, Cycle 4 – Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+7 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 12 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 4 – Planned for 8/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 13 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
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: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
HCG, QUANTITATIVE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 14 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation. Allow for adequate flushing between gemcitabine
and oxaliplatin with Dextrose 5% in Water.
oxaliplatin (ELOXATIN) 255 mg in dextrose 5 % 250 mL bag
255 mg (rounded from 254.8 mg = 130 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity risk. See emergency medications. Administer over 120 minutes. Incompatible with Sodium Chloride. Allow adequate
flushing with Dextrose 5% in Water when necessary between chemotherapy treatment medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine
and oxaliplatin for 200 minutes.
Day 8, Cycle 5 – Planned for 9/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 15 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 5 – Planned for 9/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 16 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 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: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
HCG, QUANTITATIVE
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
MD to delete if not needed.
Treatment Conditions
Verify Labs
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 17 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to oxaliplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation. Allow for adequate flushing between gemcitabine
and oxaliplatin with Dextrose 5% in Water.
oxaliplatin (ELOXATIN) 255 mg in dextrose 5 % 250 mL bag
255 mg (rounded from 254.8 mg = 130 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity risk. See emergency medications. Administer over 120 minutes. Incompatible with Sodium Chloride. Allow adequate
flushing with Dextrose 5% in Water when necessary between chemotherapy treatment medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine
and oxaliplatin for 200 minutes.
Day 8, Cycle 6 – Planned for 10/5/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 18 of 20
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: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1 and 8, oxaliplatin
130 mg/m2 IV Day 1; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,960 mg in sodium chloride 0.9 % 100 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 6 – Planned for 10/12/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/15/2017 7:57:26 AM Page 19 of 20
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: Testicular, Germ Cell Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1000 mg/m2 IV on Day 1
and 8, oxaliplatin 130 mg/m2 IV Day 1; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 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 7:57:26 AM Page 20 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org