/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/gyn/,

/clinical/cckm-tools/content/beacon-protocols/gyn/name-117730-en.cckm

20180237

page

100

UWHC,UWMF,

Tools,

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

CSC GYN Niraparib(28D:1-28) VER 2-6-18 (HL 6483)

CSC GYN Niraparib(28D:1-28) VER 2-6-18 (HL 6483) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN NIRAPARIB (28D:1-28) VER: 2-6-18 –  Properties
Pre-Cycle –  1/30/2018 through 2/5/2018 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 1/30/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE(S): Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer; THERAPY: niraparib 300 mg by mouth once
daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for maintenance treatment for patients with recurrent, platinum-sensitive epithelial
ovarian cancer, fallopian tube, or primary peritoneal cancer who had a complete or partial response to platinum-based
chemotherapy. Patients must have received at least two prior treatments of platinum-based chemotherapy.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
CA 125
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
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, E-Prescribe
Cycle 1 –  2/6/2018 through 3/5/2018 (28 days), Planned
Day 1, Cycle 1 –  Planned for 2/6/2018
Treatment Plan Information
Reference Information (1)
OVARIAN CANCER: Mirza MR, et al. N Engl J Med 2016;375(22):2154-64.
Treatment Plan Summary
DISEASE(S): Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer; THERAPY: niraparib 300 mg by mouth once
daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
2/6/2018 10:58:26 AM Page 1 of 12
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

Note to All Staff (1)
Chemotherapy Council approved for maintenance treatment for patients with recurrent, platinum-
sensitive epithelial ovarian cancer, fallopian tube, or primary peritoneal cancer who had a complete or
partial response to platinum-based chemotherapy. Patients must have received at least two prior
treatments of platinum-based chemotherapy.
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 with DIFF, AST and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 8 g/dL or AST greater than or equal to 5 X ULN or ALT greater than or equal to 5 X ULN.
Note to All Staff (1)
If dose modifications are needed for hematologic toxicity, monitor blood counts weekly until recovery.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Verify Blood Pressure and Heart Rate is completed at each clinic visit.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): niraparib (dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the medication activity).
Take Home Medications
niraparib tosylate (ZEJULA) 100 MG cap
Take 3 caps by mouth one time daily., 300 mg, Disp-90 cap, R-0, 1 X DAILY starting S, E-Prescribe
Follow-Up
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
2/6/2018 10:58:26 AM Page 2 of 12
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

DAY 8 FOLLOW-UP
LABS: CBC with DIFF.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF.
DAY 22 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, AST, ALT and CA-125.
Lab Only - Day 8, Cycle 1 –  Planned for 2/13/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE(S): Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer; THERAPY: niraparib 300 mg by mouth once
daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for maintenance treatment for patients with recurrent, platinum-sensitive epithelial
ovarian cancer, fallopian tube, or primary peritoneal cancer who had a complete or partial response to platinum-based
chemotherapy. Patients must have received at least two prior treatments of platinum-based chemotherapy.
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 WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): niraparib (dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the medication activity).
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
2/6/2018 10:58:26 AM Page 3 of 12
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 –  Planned for 2/20/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE(S): Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer; THERAPY: niraparib 300 mg by mouth once
daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for maintenance treatment for patients with recurrent, platinum-sensitive epithelial
ovarian cancer, fallopian tube, or primary peritoneal cancer who had a complete or partial response to platinum-based
chemotherapy. Patients must have received at least two prior treatments of platinum-based chemotherapy.
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 WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): niraparib (dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the medication activity).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 1 –  Planned for 2/27/2018
Treatment Plan Information
Treatment Plan Summary
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
2/6/2018 10:58:26 AM Page 4 of 12
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org

DISEASE(S): Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer; THERAPY: niraparib 300 mg by mouth once
daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for maintenance treatment for patients with recurrent, platinum-sensitive epithelial
ovarian cancer, fallopian tube, or primary peritoneal cancer who had a complete or partial response to platinum-based
chemotherapy. Patients must have received at least two prior treatments of platinum-based chemotherapy.
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 WITH DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): niraparib (dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the medication activity).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  3/6/2018 through 4/2/2018 (28 days), Planned
Day 1, Cycle 2 –  Planned for 3/6/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE(S): Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer; THERAPY: niraparib 300 mg by mouth once
daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for maintenance treatment for patients with recurrent, platinum-sensitive epithelial
ovarian cancer, fallopian tube, or primary peritoneal cancer who had a complete or partial response to platinum-based
chemotherapy. Patients must have received at least two prior treatments of platinum-based chemotherapy.
Consent
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
2/6/2018 10:58:26 AM Page 5 of 12
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Routine
CA 125
Expected: S+28 Approximate, Expires: S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, AST and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 8 g/dL or AST greater than or equal to 5 X ULN or ALT greater than or equal to 5 X ULN.
Note to All Staff (1)
If dose modifications are needed for hematologic toxicity, monitor blood counts weekly until recovery.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Verify Blood Pressure and Heart Rate is completed at each clinic visit.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
2/6/2018 10:58:26 AM Page 6 of 12
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org

Refer to the Take Home Medications section for the following treatment medication(s): niraparib (dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the medication activity).
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, AST, ALT and CA-125.
Cycle 3 –  4/3/2018 through 4/30/2018 (28 days), Planned
Day 1, Cycle 3 –  Planned for 4/3/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE(S): Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer; THERAPY: niraparib 300 mg by mouth once
daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for maintenance treatment for patients with recurrent, platinum-sensitive epithelial
ovarian cancer, fallopian tube, or primary peritoneal cancer who had a complete or partial response to platinum-based
chemotherapy. Patients must have received at least two prior treatments of platinum-based chemotherapy.
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 WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Routine
CA 125
Expected: S+28 Approximate, Expires: S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, AST and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 8 g/dL or AST greater than or equal to 5 X ULN or ALT greater than or equal to 5 X ULN.
Note to All Staff (1)
If dose modifications are needed for hematologic toxicity, monitor blood counts weekly until recovery.
Nursing Procedure, Assessment and Monitoring
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
2/6/2018 10:58:26 AM Page 7 of 12
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org

Monitoring Parameters (1)
Verify Blood Pressure and Heart Rate is completed at each clinic visit.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): niraparib (dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the medication activity).
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, AST, ALT and CA-125.
Cycle 4 –  5/1/2018 through 5/28/2018 (28 days), Planned
Day 1, Cycle 4 –  Planned for 5/1/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE(S): Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer; THERAPY: niraparib 300 mg by mouth once
daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for maintenance treatment for patients with recurrent, platinum-sensitive epithelial
ovarian cancer, fallopian tube, or primary peritoneal cancer who had a complete or partial response to platinum-based
chemotherapy. Patients must have received at least two prior treatments of platinum-based chemotherapy.
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 WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
AST/SGOT
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
2/6/2018 10:58:26 AM Page 8 of 12
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org

Expected: S+28 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Routine
CA 125
Expected: S+28 Approximate, Expires: S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, AST and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 8 g/dL or AST greater than or equal to 5 X ULN or ALT greater than or equal to 5 X ULN.
Note to All Staff (1)
If dose modifications are needed for hematologic toxicity, monitor blood counts weekly until recovery.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Verify Blood Pressure and Heart Rate is completed at each clinic visit.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): niraparib (dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the medication activity).
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, AST, ALT and CA-125.
Cycle 5 –  5/29/2018 through 6/25/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 5/29/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE(S): Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer; THERAPY: niraparib 300 mg by mouth once
daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
2/6/2018 10:58:26 AM Page 9 of 12
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org

Chemotherapy Council approved for maintenance treatment for patients with recurrent, platinum-
sensitive epithelial ovarian cancer, fallopian tube, or primary peritoneal cancer who had a complete or
partial response to platinum-based chemotherapy. Patients must have received at least two prior
treatments of platinum-based chemotherapy.
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 WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Routine
CA 125
Expected: S+28 Approximate, Expires: S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, AST and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 8 g/dL or AST greater than or equal to 5 X ULN or ALT greater than or equal to 5 X ULN.
Note to All Staff (1)
If dose modifications are needed for hematologic toxicity, monitor blood counts weekly until recovery.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Verify Blood Pressure and Heart Rate is completed at each clinic visit.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
2/6/2018 10:58:26 AM Page 10 of 12
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): niraparib (dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the medication activity).
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, AST, ALT and CA-125.
Cycle 6 –  6/26/2018 through 7/23/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 6/26/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE(S): Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer; THERAPY: niraparib 300 mg by mouth once
daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for maintenance treatment for patients with recurrent, platinum-sensitive epithelial
ovarian cancer, fallopian tube, or primary peritoneal cancer who had a complete or partial response to platinum-based
chemotherapy. Patients must have received at least two prior treatments of platinum-based chemotherapy.
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 WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Routine
CA 125
Expected: S+28 Approximate, Expires: S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, AST and ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 8 g/dL or AST greater than or equal to 5 X ULN or ALT greater than or equal to 5 X ULN.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
2/6/2018 10:58:26 AM Page 11 of 12
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org

Note to All Staff (1)
If dose modifications are needed for hematologic toxicity, monitor blood counts weekly until recovery.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Verify Blood Pressure and Heart Rate is completed at each clinic visit.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): niraparib (dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the medication activity).
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, AST, ALT and CA-125.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
2/6/2018 10:58:26 AM Page 12 of 12
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2018CCKM@uwhealth.org