/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-96743-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) Gemcitabine(21D:1,8) VER 1-11-17 (HL 549)

CSC GYN Carboplatin(21D:1) Gemcitabine(21D:1,8) VER 1-11-17 (HL 549) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN CARBOPLATIN(21D:1)/GEMCITABINE(21D:1,8) 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, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
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, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S, Expires-S+365, Routine
POTASSIUM
Expected-S, Expires-S+365, Routine
CA 125
Expected-S, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S, Expires-S+365, Routine
CREATININE
Expected-S, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tablet by mouth twice daily for 2 days after chemotherapy and every 8 hours as needed thereafter., Disp-30 tab, R-5, 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)
OVARIAN, PRIMARY PERITONEAL, FALLOPIAN TUBE CANCER: Pfisterer J, et al. J Clin Oncol 2006;24(29):4699-707.
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 1 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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.
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 2 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 4), 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 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and CARBOplatin
for 120 minutes.
Day 8, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
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+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 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 3 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Labs Only - Day 15, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 4 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365
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.
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 5 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
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
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 4), 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 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and CARBOplatin
for 120 minutes.
Day 8, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 6 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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+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 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
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 5:33:52 PM Page 7 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Labs Only - Day 15, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 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, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 8 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365
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.
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 9 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 4), 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 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and CARBOplatin
for 120 minutes.
Day 8, Cycle 3 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
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+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 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 10 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Labs Only - Day 15, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 11 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365
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.
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.
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 5:33:52 PM Page 12 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
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
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 4), 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 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and CARBOplatin
for 120 minutes.
Day 8, Cycle 4 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
Note to All Staff (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 13 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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+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 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Labs Only - Day 15, Cycle 4 – Planned for 8/22/2017
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 14 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 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, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 15 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365
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.
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 16 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 4), 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 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and CARBOplatin
for 120 minutes.
Day 8, Cycle 5 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
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+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 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
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 5:33:52 PM Page 17 of 22
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Labs Only - Day 15, Cycle 5 – Planned for 9/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 18 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365
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.
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.
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 5:33:52 PM Page 19 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
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
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 4), 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 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and CARBOplatin
for 120 minutes.
Day 8, Cycle 6 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
Note to All Staff (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 20 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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+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 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Labs Only - Day 15, Cycle 6 – Planned for 10/3/2017
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Zztestonc,Edward E [2435061]
6/6/2017 5:33:52 PM Page 21 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Primary Peritoneal, Fallopian Tube Cancer (Adjuvant/Advanced); THERAPY:
gemcitabine 1000 mg/m2 IV Days 1 and 8; CARBOplatin (AUC=4) IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 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 5:33:52 PM Page 22 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org