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/clinical/cckm-tools/content/beacon-protocols/gyn/name-105385-en.cckm

201706157

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100

UWHC,UWMF,

Tools,

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

CSC GYN Concurrent XRT Cisplatin(21D:1,8,15) VER 1-11-17 (HL 5804)

CSC GYN Concurrent XRT Cisplatin(21D:1,8,15) VER 1-11-17 (HL 5804) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN CONCURRENT XRT CISPLATIN(21D:1,8,15) VER: 4-24-17 – Properties
Pre-Cycle – 5/30/2017 through 6/5/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Neo-adjuvant/Local/Adjuvant/Advanced); THERAPY: CISplatin 40 mg/m2 IV (maximum
dose = 70 mg) on Days 1, 8 and 15 concurrent with radiation; CYCLE LENGTH: 21 days; COURSE: Until XRT Complete
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
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following CISplatin., 80 mg, Disp-2 cap, R-5, 1 X DAILY starting S
dexamethasone (DECADRON) 2 MG tab
Take 1 tab by mouth one time daily. Take for 2 days following chemotherapy., 2 mg, Disp-12 tab, R-0, 1 X DAILY starting S
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
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 6/6/2017 through 6/26/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
CERVICAL, VULVAR, VAGINAL CANCER: Lanciano R, et al. J Clin Oncol 2005;23(33):8289-95.
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Neo-adjuvant/Local/Adjuvant/Advanced); THERAPY: CISplatin 40 mg/m2 IV (maximum
dose = 70 mg) on Days 1, 8 and 15 concurrent with radiation; CYCLE LENGTH: 21 days; COURSE: Until XRT Complete
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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Zztestonc,Edward E [2435061]
6/6/2017 6:34:57 PM Page 1 of 10
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.
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 500/µL or Platelets less than or equal to 50K/µL or Hemoglobin
less than 9 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Measure Urine Output
SEE COMMENTS Starting when released Until Specified
Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
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% with KCl 20 mEq/L infusion
at 999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Administer over 1 hour prior to starting CISplatin infusion.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 4 mg
4 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 80 mg in sodium chloride 0.9 % 1,000 mL bag
80 mg (40 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
For 60 to 90 minutes. Maximum dose = 70 mg.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium, Creatinine; CHEMOTHERAPY ROOM APPOINTMENT:
CISplatin for 180 minutes. RADIOLOGY: Prior to discharge, confirm XRT scheduled (if applicable).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium, Creatinine; CHEMOTHERAPY ROOM APPOINTMENT:
CISplatin for 180 minutes. RADIOLOGY: Prior to discharge, confirm XRT scheduled (if applicable).
DAY 22 FOLLOW-UP
Ordered dose of 40 mg/m2 ONCE exceeds the recommended single dose limit of 70 mg.
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Zztestonc,Edward E [2435061]
6/6/2017 6:34:57 PM Page 2 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin for 180 minutes. RADIOLOGY: Prior to discharge,
confirm XRT scheduled (if applicable).
Day 8, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Neo-adjuvant/Local/Adjuvant/Advanced); THERAPY: CISplatin 40 mg/m2 IV (maximum
dose = 70 mg) on Days 1, 8 and 15 concurrent with radiation; CYCLE LENGTH: 21 days; COURSE: Until XRT Complete
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 500/µL or Platelets less than or equal to 50K/µL or Hemoglobin
less than 9 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Measure Urine Output
SEE COMMENTS Starting when released Until Specified
Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
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% with KCl 20 mEq/L infusion
at 999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Administer over 1 hour prior to starting CISplatin infusion.
Pre-Medications
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Zztestonc,Edward E [2435061]
6/6/2017 6:34:57 PM Page 3 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 4 mg
4 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 80 mg in sodium chloride 0.9 % 1,000 mL bag
80 mg (40 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
For 60 to 90 minutes. Maximum dose = 70 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Neo-adjuvant/Local/Adjuvant/Advanced); THERAPY: CISplatin 40 mg/m2 IV (maximum
dose = 70 mg) on Days 1, 8 and 15 concurrent with radiation; CYCLE LENGTH: 21 days; COURSE: Until XRT Complete
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 500/µL or Platelets less than or equal to 50K/µL or Hemoglobin
less than 9 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Measure Urine Output
SEE COMMENTS Starting when released Until Specified
Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
Ordered dose of 40 mg/m2 ONCE exceeds the recommended single dose limit of 70 mg.
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Zztestonc,Edward E [2435061]
6/6/2017 6:34:57 PM Page 4 of 10
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% with KCl 20 mEq/L infusion
at 999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Administer over 1 hour prior to starting CISplatin infusion.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 4 mg
4 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 80 mg in sodium chloride 0.9 % 1,000 mL bag
80 mg (40 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
For 60 to 90 minutes. Maximum dose = 70 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 6/27/2017 through 7/17/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Neo-adjuvant/Local/Adjuvant/Advanced); THERAPY: CISplatin 40 mg/m2 IV (maximum
dose = 70 mg) on Days 1, 8 and 15 concurrent with radiation; CYCLE LENGTH: 21 days; COURSE: Until XRT Complete
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
Ordered dose of 40 mg/m2 ONCE exceeds the recommended single dose limit of 70 mg.
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Zztestonc,Edward E [2435061]
6/6/2017 6:34:57 PM Page 5 of 10
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
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 500/µL or Platelets less than or equal to 50K/µL or Hemoglobin
less than 9 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Measure Urine Output
SEE COMMENTS Starting when released Until Specified
Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
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% with KCl 20 mEq/L infusion
at 999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Administer over 1 hour prior to starting CISplatin infusion.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 4 mg
4 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 80 mg in sodium chloride 0.9 % 1,000 mL bag
80 mg (40 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
For 60 to 90 minutes. Maximum dose = 70 mg.
Follow-Up
DAY 8 FOLLOW-UP
Ordered dose of 40 mg/m2 ONCE exceeds the recommended single dose limit of 70 mg.
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Zztestonc,Edward E [2435061]
6/6/2017 6:34:57 PM Page 6 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium, Creatinine; CHEMOTHERAPY ROOM
APPOINTMENT: CISplatin for 180 minutes. RADIOLOGY: Prior to discharge, confirm XRT scheduled (if
applicable).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium, Creatinine; CHEMOTHERAPY ROOM APPOINTMENT:
CISplatin for 180 minutes. RADIOLOGY: Prior to discharge, confirm XRT scheduled (if applicable).
DAY 22 FOLLOW-UP
RETURN TO RADIATION ONCOLOGY CLINIC for appointment with radiation oncology provider; LABS (Weekly for 2 Weeks): CBC,
ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine; LABS (Weekly for 4 Weeks): Magnesium.
Day 8, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Neo-adjuvant/Local/Adjuvant/Advanced); THERAPY: CISplatin 40 mg/m2 IV (maximum
dose = 70 mg) on Days 1, 8 and 15 concurrent with radiation; CYCLE LENGTH: 21 days; COURSE: Until XRT Complete
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 500/µL or Platelets less than or equal to 50K/µL or Hemoglobin
less than 9 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Measure Urine Output
SEE COMMENTS Starting when released Until Specified
Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Edward E [2435061]
6/6/2017 6:34:57 PM Page 7 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% with KCl 20 mEq/L infusion
at 999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Administer over 1 hour prior to starting CISplatin infusion.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 4 mg
4 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 80 mg in sodium chloride 0.9 % 1,000 mL bag
80 mg (40 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
For 60 to 90 minutes. Maximum dose = 70 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Neo-adjuvant/Local/Adjuvant/Advanced); THERAPY: CISplatin 40 mg/m2 IV (maximum
dose = 70 mg) on Days 1, 8 and 15 concurrent with radiation; CYCLE LENGTH: 21 days; COURSE: Until XRT Complete
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Ordered dose of 40 mg/m2 ONCE exceeds the recommended single dose limit of 70 mg.
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Zztestonc,Edward E [2435061]
6/6/2017 6:34:57 PM Page 8 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than or equal to 500/µL or Platelets less than or equal to 50K/µL or Hemoglobin
less than 9 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Measure Urine Output
SEE COMMENTS Starting when released Until Specified
Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
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% with KCl 20 mEq/L infusion
at 999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Administer over 1 hour prior to starting CISplatin infusion.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 4 mg
4 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 80 mg in sodium chloride 0.9 % 1,000 mL bag
80 mg (40 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
For 60 to 90 minutes. Maximum dose = 70 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 7/18/2017 through 8/7/2017 (21 days), Planned
Day 1 - Lab Only, Cycle 3 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Neo-adjuvant/Local/Adjuvant/Advanced); THERAPY: CISplatin 40 mg/m2 IV (maximum
dose = 70 mg) on Days 1, 8 and 15 concurrent with radiation; CYCLE LENGTH: 21 days; COURSE: Until XRT Complete
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.
Ordered dose of 40 mg/m2 ONCE exceeds the recommended single dose limit of 70 mg.
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Zztestonc,Edward E [2435061]
6/6/2017 6:34:57 PM Page 9 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expires-S+21, Interval-Weekly, Count-2, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expires-S+21, Interval-Weekly, Count-2, Normal, Routine
ELECTROLYTES
Expires-S+21, Interval-Weekly, Count-2, Normal, Routine
GLUCOSE
Expires-S+21, Interval-Weekly, Count-2, Normal, Routine
BUN
Expires-S+21, Interval-Weekly, Count-2, Normal, Routine
CREATININE
Expires-S+21, Interval-Weekly, Count-2, Normal, Routine
CALCIUM
Expires-S+21, Interval-Weekly, Count-2, Normal, Routine
MAGNESIUM
Expires-S+35, Interval-Weekly, Count-4, Normal, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 6:34:57 PM Page 10 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org