/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-96742-en.cckm

201706157

page

100

UWHC,UWMF,

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

CSC GYN Carboplatin(21D:1) Docetaxel(21D:1) VER 1-11-17 (HL 391)

CSC GYN Carboplatin(21D:1) Docetaxel(21D:1) VER 1-11-17 (HL 391) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN CARBOPLATIN(21D:1)/DOCETAXEL(21D:1) 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 (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
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
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
CA 125
Expected-S Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth 2 times daily. Take for 3 days, starting AM on the day prior to DOCEtaxel., 8 mg, Disp-36 tab, R-1, 2 X
DAILY starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 6/6/2017 through 6/26/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 1 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

OVARIAN, PRIMARY PERITONEAL, FALLOPIAN TUBE, UTERINE, CERVICAL, VULVAR, VAGINAL CANCER:
Vasey PA, et al. J Natl Cancer Inst 2004;96:1682-91.
Treatment Plan Summary
DISEASE: Ovarian (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
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 CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity to DOCEtaxel 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 18mL 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 DOCEtaxel 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 5:03:30 PM Page 2 of 17
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 20 mg
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.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
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
DOCEtaxel (TAXOTERE) in dextrose 5 % 100 mL non-PVC bag
Intravenous, ONCE, 1 dose Starting when released
For 60 minutes. Maximum BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency medications. In non-PVC
bag. Infuse through non PVC tubing.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Magnesium, Glucose, BUN, Creatinine, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel and
CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 3 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 6/27/2017 through 7/17/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
CA 125
Expected-S+21 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 4 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
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 CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity to DOCEtaxel 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 18mL 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 DOCEtaxel 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
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.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 5 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
DOCEtaxel (TAXOTERE) in dextrose 5 % 100 mL non-PVC bag
Intravenous, ONCE, 1 dose Starting when released
For 60 minutes. Maximum BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency medications. In non-PVC
bag. Infuse through non PVC tubing.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Magnesium, Glucose, BUN, Creatinine, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel and
CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 2 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 7/18/2017 through 8/7/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 6 of 17
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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
CA 125
Expected-S+21 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
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 CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity to DOCEtaxel 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 18mL 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 7 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 DOCEtaxel 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
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.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
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
DOCEtaxel (TAXOTERE) in dextrose 5 % 100 mL non-PVC bag
Intravenous, ONCE, 1 dose Starting when released
For 60 minutes. Maximum BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency medications. In non-PVC
bag. Infuse through non PVC tubing.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Magnesium, Glucose, BUN, Creatinine, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel and
CARBOplatin for 150 minutes.
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 8 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Lab Only - Day 10, Cycle 3 – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 8/8/2017 through 8/28/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 9 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CA 125
Expected-S+21 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
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 CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity to DOCEtaxel 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 18mL 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 DOCEtaxel 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 5:03:30 PM Page 10 of 17
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.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
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
DOCEtaxel (TAXOTERE) in dextrose 5 % 100 mL non-PVC bag
Intravenous, ONCE, 1 dose Starting when released
For 60 minutes. Maximum BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency medications. In non-PVC
bag. Infuse through non PVC tubing.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Magnesium, Glucose, BUN, Creatinine, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel and
CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 11 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 8/29/2017 through 9/18/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
CA 125
Expected-S+21 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Verify Medication(s) Taken at Home (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 12 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity to DOCEtaxel 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 18mL 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 DOCEtaxel 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
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.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
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
DOCEtaxel (TAXOTERE) in dextrose 5 % 100 mL non-PVC bag
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 13 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Intravenous, ONCE, 1 dose Starting when released
For 60 minutes. Maximum BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency medications. In non-PVC
bag. Infuse through non PVC tubing.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Magnesium, Glucose, BUN, Creatinine, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel and
CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 5 – Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 9/19/2017 through 10/9/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 14 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
CA 125
Expected-S+21 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
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 CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity to DOCEtaxel 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 18mL 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 DOCEtaxel 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 15 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
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.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
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
DOCEtaxel (TAXOTERE) in dextrose 5 % 100 mL non-PVC bag
Intravenous, ONCE, 1 dose Starting when released
For 60 minutes. Maximum BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency medications. In non-PVC
bag. Infuse through non PVC tubing.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Magnesium, Glucose, BUN, Creatinine, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel and
CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 6 – Planned for 9/28/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 16 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian (Adjuvant/Advanced), Primary Peritoneal, Fallopian Tube, Uterine, Cervical, Vulvar, Vaginal Cancer;
THERAPY: DOCEtaxel 60 to 75mg/m2 IV Day 1, CARBOplatin (AUC = 4 to 6) IV Day 1;
CYCLE LENGTH: 21 days; COURSE: 4 to 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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Edward E [2435061]
6/6/2017 5:03:30 PM Page 17 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org