/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-96737-en.cckm

201706157

page

100

UWHC,UWMF,

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

CSC GYN Bevacizumab(28D:1,15) Paclitaxel(28D:1,8,15,22) VER 1-11-17 (HL 3163)

CSC GYN Bevacizumab(28D:1,15) Paclitaxel(28D:1,8,15,22) VER 1-11-17 (HL 3163) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN BEVACIZUMAB(28D:1,15)/PACLITAXEL(28D:1,8,15,22) VER: 1-11-17 – 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: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S Approximate, Expires-S+365, Routine
CA 125
Expected-S Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer.
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,
Local Printer
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs 12&6 hrs prior to 1st PACLItaxel dose, 3 tabs 12&6 hrs prior to 2nd dose, 2 tabs 12&6 hrs prior to 3rd dose, Disp-20
tab, R-0, starting S
Cycle 1 – 6/6/2017 through 7/3/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
OVARIAN, FALLOPIAN TUBE, PRIMARY PERITONEAL CANCER: Monk BJ et al. Gyncol Oncol 2005;96:902-5.
Reference Information (2)
OVARIAN/FALLOPIAN TUBE/PRIMARY PERITONEAL: Le L, et al. Gyn Oncol 2006;102:49-53.
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 1 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Treatment Conditions
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 2 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 794 mg in sodium chloride 0.9 % 100 mL bag
794 mg (10 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses over 30 minutes.
If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Hypersensitivity risk. See Emergency Medications.
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab and PACLItaxel for 150
minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Magnesium, Creatinine, Urinalysis with Microscopy, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab and
PACLItaxel for 120 minutes.
Day 8, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
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.
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 3 of 43
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
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, PRN - NOTIFY PHARMACY WHEN NEEDED Starting when released Until Discontinued, If PO not taken at
home.
For use in patients who did not take dexamethasone at home. Notify pharmacy that medication is needed
Emergency Medications
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 4 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
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: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
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
URINALYSIS WITH MICROSCOPY
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 5 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, PRN - NOTIFY PHARMACY WHEN NEEDED Starting when released Until Discontinued, If PO not taken at
home.
For use in patients who did not take dexamethasone at home. Notify pharmacy that medication is needed
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 794 mg in sodium chloride 0.9 % 100 mL bag
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 6 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

794 mg (10 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses over 30 minutes.
If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Hypersensitivity risk. See Emergency Medications.
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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,Edward E [2435061]
6/6/2017 5:58:57 PM Page 7 of 43
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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/4/2017 through 7/31/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 8 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
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
URINALYSIS WITH MICROSCOPY
Expected-S+7 Approximate, Expires-S+365, Routine
CA 125
Expected-S+7 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 9 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 794 mg in sodium chloride 0.9 % 100 mL bag
794 mg (10 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses over 30 minutes.
If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Hypersensitivity risk. See Emergency Medications.
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab and PACLItaxel for 150
minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Magnesium, Creatinine, Urinalysis with Microscopy, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab and
PACLItaxel for 120 minutes.
Day 8, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 10 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 11 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
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 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
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
URINALYSIS WITH MICROSCOPY
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 12 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 794 mg in sodium chloride 0.9 % 100 mL bag
794 mg (10 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses over 30 minutes.
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 13 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Hypersensitivity risk. See Emergency Medications.
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 2 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 5:58:57 PM Page 14 of 43
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 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 8/1/2017 through 8/28/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 15 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
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
URINALYSIS WITH MICROSCOPY
Expected-S+7 Approximate, Expires-S+365, Routine
CA 125
Expected-S+7 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 16 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 794 mg in sodium chloride 0.9 % 100 mL bag
794 mg (10 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses over 30 minutes.
If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Hypersensitivity risk. See Emergency Medications.
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab and PACLItaxel for 150
minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Magnesium, Creatinine, Urinalysis with Microscopy, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab and
PACLItaxel for 120 minutes.
Day 8, Cycle 3 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 17 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 18 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
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
URINALYSIS WITH MICROSCOPY
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 19 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 794 mg in sodium chloride 0.9 % 100 mL bag
794 mg (10 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses over 30 minutes.
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 20 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Hypersensitivity risk. See Emergency Medications.
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 3 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 5:58:57 PM Page 21 of 43
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 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 8/29/2017 through 9/25/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 22 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
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
URINALYSIS WITH MICROSCOPY
Expected-S+7 Approximate, Expires-S+365, Routine
CA 125
Expected-S+7 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 23 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 794 mg in sodium chloride 0.9 % 100 mL bag
794 mg (10 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses over 30 minutes.
If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Hypersensitivity risk. See Emergency Medications.
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab and PACLItaxel for 150
minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Magnesium, Creatinine, Urinalysis with Microscopy, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab and
PACLItaxel for 120 minutes.
Day 8, Cycle 4 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 24 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 25 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 – Planned for 9/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
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
URINALYSIS WITH MICROSCOPY
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 26 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 794 mg in sodium chloride 0.9 % 100 mL bag
794 mg (10 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses over 30 minutes.
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 27 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Hypersensitivity risk. See Emergency Medications.
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 4 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 5:58:57 PM Page 28 of 43
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 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 9/26/2017 through 10/23/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 29 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
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
URINALYSIS WITH MICROSCOPY
Expected-S+7 Approximate, Expires-S+365, Routine
CA 125
Expected-S+7 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 30 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 794 mg in sodium chloride 0.9 % 100 mL bag
794 mg (10 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses over 30 minutes.
If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Hypersensitivity risk. See Emergency Medications.
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab and PACLItaxel for 150
minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Magnesium, Creatinine, Urinalysis with Microscopy, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab and
PACLItaxel for 120 minutes.
Day 8, Cycle 5 – Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 31 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 32 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 – Planned for 10/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
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
URINALYSIS WITH MICROSCOPY
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 33 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 794 mg in sodium chloride 0.9 % 100 mL bag
794 mg (10 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses over 30 minutes.
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 34 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Hypersensitivity risk. See Emergency Medications.
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 5 – Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 5:58:57 PM Page 35 of 43
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 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 10/24/2017 through 11/20/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 10/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 36 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
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
URINALYSIS WITH MICROSCOPY
Expected-S+7 Approximate, Expires-S+365, Routine
CA 125
Expected-S+7 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 37 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 794 mg in sodium chloride 0.9 % 100 mL bag
794 mg (10 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses over 30 minutes.
If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Hypersensitivity risk. See Emergency Medications.
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab and PACLItaxel for 150
minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Magnesium, Creatinine, Urinalysis with Microscopy, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: bevacizumab and
PACLItaxel for 120 minutes.
Day 8, Cycle 6 – Planned for 10/31/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 38 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 39 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 – Planned for 11/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
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
URINALYSIS WITH MICROSCOPY
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Protein.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
protein greater than or equal to 100 mg/dL or Blood Pressure greater than or equal to 160/90mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 40 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of bevacizumab.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 794 mg in sodium chloride 0.9 % 100 mL bag
794 mg (10 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
First dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses over 30 minutes.
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 41 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated.
Hypersensitivity risk. See Emergency Medications.
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 6 – Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Primary Peritoneal Cancer (Advanced); THERAPY: bevacizumab 10 mg/kg IV Day 1 and Day
15, PACLItaxel 80 to 100 mg/m2 IV Day 1,8,15, and 22; CYCLE LENGTH: 28 days; COURSE: 6 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 5:58:57 PM Page 42 of 43
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 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during
administration.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Edward E [2435061]
6/6/2017 5:58:57 PM Page 43 of 43
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org