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/clinical/cckm-tools/content/beacon-protocols/gu/name-96724-en.cckm

201706166

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100

UWHC,UWMF,

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

CSC GU Topotecan(21D:1-5) VER 12-1-16 (HL 721)

CSC GU Topotecan(21D:1-5) VER 12-1-16 (HL 721) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU TOPOTECAN(21D:1-5) VER: 12-1-16 (HL 721) – 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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
CREATININE
Expected-S Approximate, Expires-S+365, Routine
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
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: Ardizzoni A, et al. J Clin Onc 1997;15:2090-6.
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 1 of 29
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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
DAY 2, 3, 4, and 5: CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC,ANC (differential if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: topotecan for 60 minutes.
Day 2, Cycle 1 – Planned for 6/16/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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.
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 2 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 3 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
IV Access
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 4 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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 8:05:56 AM Page 5 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 6 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
DAY 2, 3, 4, and 5: CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC,ANC (differential if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: topotecan for 60 minutes.
Day 2, Cycle 2 – Planned for 7/7/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 7 of 29
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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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 7/9/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 8 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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 7/10/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 9 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 10 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
DAY 2, 3, 4, and 5: CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC,ANC (differential if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: topotecan for 60 minutes.
Day 2, Cycle 3 – Planned for 7/28/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 11 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 12 of 29
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
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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 3 – Planned for 7/30/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 13 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 3 – Planned for 7/31/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 14 of 29
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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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 8:05:56 AM Page 15 of 29
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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
DAY 2, 3, 4, and 5: CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC,ANC (differential if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: topotecan for 60 minutes.
Day 2, Cycle 4 – Planned for 8/18/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 16 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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 8:05:56 AM Page 17 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Day 4, Cycle 4 – Planned for 8/20/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 4 – Planned for 8/21/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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 8:05:56 AM Page 18 of 29
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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 19 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5
mg/m2 IV Day 1 through 5; 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+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 20 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 2, 3, 4, and 5: CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC,ANC (differential if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: topotecan for 60 minutes.
Day 2, Cycle 5 – Planned for 9/8/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
IV Access
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 21 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 5 – Planned for 9/10/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 22 of 29
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
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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 5 – Planned for 9/11/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 23 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 24 of 29
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: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
DAY 2, 3, 4, and 5: CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC,ANC (differential if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: topotecan for 60 minutes.
Day 2, Cycle 6 – Planned for 9/29/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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 8:05:56 AM Page 25 of 29
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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 26 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 6 – Planned for 10/1/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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 8:05:56 AM Page 27 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Day 5, Cycle 6 – Planned for 10/2/2017
Treatment Plan Information
Treatment Plan Summary
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 2.94 mg in sodium chloride 0.9 % 100 mL bag
2.94 mg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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
Prostate Cancer (Advanced/Neuroendocrine features/extrapulmonary small cell tumor); THERAPY: topotecan 1.5 mg/m2 IV Day 1
through 5; 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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:05:56 AM Page 28 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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 8:05:56 AM Page 29 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org