/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-96745-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) Paclitaxel(21D:1,8,15) VER 1-11-17 (HL 3457)

CSC GYN Carboplatin(21D:1) Paclitaxel(21D:1,8,15) VER 1-11-17 (HL 3457) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN CARBOPLATIN (21D:1)PACLITAXEL (21D:1,8,15) VER: 1-11-17 – Properties
Pre-Cycle – 5/30/2017 through 6/5/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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 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 5 tablets 12&6h prior to 1st dose of PACLItaxel., Disp-10 tab, R-0, starting S
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, FALLOPIAN TUBE, AND PERITONEAL CANCERS: Katsumata, N. et al, Lancet (2009); 374:1331-8.
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 1 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80
mg/m2 IV Day 1, 8 and 15, CARBOplatin (AUC = 4 to 6) 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.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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.
Hypersensitivity Monitoring (2)
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.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 2 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
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.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 3 tabs 12&6 hrs prior to 2nd PACLItaxel dose and 2 tabs once daily for 3 days after CARBOplatin., Disp-12 tab, R-0,
starting S
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
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),
Electrolytes, Magnesium, Glucose, BUN, Creatinine, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT:
PACLItaxel and CARBOplatin for 180 minutes.
Day 8, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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 6:00:33 PM Page 3 of 35
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.
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 if ANC less than 500/µL or Platelets less than 50K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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 PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 4 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, PRN - NOTIFY PHARMACY WHEN NEEDED Starting when released Until Discontinued, If PO not taken at
home.
For use in patients who did not take dexamethasone at home. Notify pharmacy that medication is needed
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs 12&6 hrs prior to 3rd PACLItaxel dose and 2 tabs once daily for 3 days after CARBOplatin., Disp-40 tab, R-0, starting S,
Local Printer
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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.
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 6:00:33 PM Page 5 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber if ANC less than 500/µL or Platelets less than 50K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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 PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, PRN - NOTIFY PHARMACY WHEN NEEDED Starting when released Until Discontinued, If PO not taken at
home.
For use in patients who did not take dexamethasone at home. Notify pharmacy that medication is needed
Emergency Medications
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 6 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
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, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
CA 125
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 7 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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.
Hypersensitivity Monitoring (2)
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.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 8 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
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 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
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),
Electrolytes, Magnesium, Glucose, BUN, Creatinine, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT:
PACLItaxel and CARBOplatin for 180 minutes.
Day 8, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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.
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
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 9 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 if ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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 PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 10 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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.
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 if ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 11 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
Follow-Up
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 12 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
CA 125
Expected-S+7 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 13 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
** Rush dextrose primed line with 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.
Hypersensitivity Monitoring (2)
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.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 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
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 14 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
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 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
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),
Electrolytes, Magnesium, Glucose, BUN, Creatinine, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT:
PACLItaxel and CARBOplatin for 180 minutes.
Day 8, Cycle 3 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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.
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 if ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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.
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 15 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent
doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 16 of 35
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.
Day 15, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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.
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 if ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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 PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 17 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
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, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 18 of 35
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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
CA 125
Expected-S+7 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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.
Hypersensitivity Monitoring (2)
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.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 19 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
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 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
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),
Electrolytes, Magnesium, Glucose, BUN, Creatinine, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT:
PACLItaxel and CARBOplatin for 180 minutes.
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 20 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Day 8, Cycle 4 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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.
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 if ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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 PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 21 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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.
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
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 22 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 if ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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 PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
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
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 23 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
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, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
CA 125
Expected-S+7 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 24 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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.
Hypersensitivity Monitoring (2)
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.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 25 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
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 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
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),
Electrolytes, Magnesium, Glucose, BUN, Creatinine, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT:
PACLItaxel and CARBOplatin for 180 minutes.
Day 8, Cycle 5 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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.
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
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 26 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber if ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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 PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
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
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 27 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 – Planned for 9/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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.
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 if ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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 PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 28 of 35
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.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
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
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 29 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Day 1, Cycle 6 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
CA 125
Expected-S+7 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 30 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 31 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
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 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 90 minutes.
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),
Electrolytes, Magnesium, Glucose, BUN, Creatinine, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT:
PACLItaxel and CARBOplatin for 180 minutes.
Day 8, Cycle 6 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8
and 15, CARBOplatin (AUC = 4 to 6) 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.
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 if ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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 PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 32 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 – Planned for 10/3/2017
Treatment Plan Information
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 33 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, and Peritoneal Cancers (Adjuvant or Advanced). THERAPY: PACLItaxel 80
mg/m2 IV Day 1, 8 and 15, CARBOplatin (AUC = 4 to 6) 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.
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 if ANC less than 500/µL or Platelets less than 50K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 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 PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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Zztestonc,Edward E [2435061]
6/6/2017 6:00:33 PM Page 34 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 160 mg in dextrose 5 % 250 mL non-PVC bag
160 mg (80 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.2 or 0.22 micron in-line non-DEHP (non-PVC) filter during administration.
Administer over 60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See Emergency Medications.
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 6:00:33 PM Page 35 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org