/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-96746-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(28D:1) Liposomal Doxorubicin(28D:1) VER 1-11-17 (HL 1953)

CSC GYN Carboplatin(28D:1) Liposomal Doxorubicin(28D:1) VER 1-11-17 (HL 1953) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN CARBOPLATIN(28D:1)/LIPOSOMAL DOXORUBICIN(28D:1) VER: 1-11-17 – Properties
Pre-Cycle – 5/30/2017 through 6/5/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S Approximate, Expires-S+365, Normal, Routine
For ovarian, fallopian tube, and primary peritoneal cancer
CREATININE
Expected-S Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tablet by mouth twice daily for 2 days after chemotherapy and every 8 hours as needed thereafter., Disp-30 tab, R-5, starting
S, Local Printer
Cycle 1 – 6/6/2017 through 7/3/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
OVARIAN/PERITONEAL/FALLOPIAN TUBE CANCER (ADVANCED): Pujade-Lauraine E, et al. J Clin Oncol. 2010;28(20): 3323-29.
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 1 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 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 without DIFF, ANC, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.2 mg/dL or AST or ALT greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to liposomal DOXOrubicin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of LIPOSOMAL doxorubicin and then every 30 minutes for
any subsequent doses.
Patient Instructions(1)
Liposomal DOXOrubicin: Educate patient about hand-foot syndrome and mucositis.
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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours before doxorubicin LIPOSOMAL to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 2 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 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
doxorubicin LIPOSOMAL (DOXIL) 60 mg in dextrose 5 % 250 mL bag
60 mg (30 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Infuse first dose at a rate of 50 mL/hr for 15 minutes then increase to 100 mL/hr for 15 minutes and if tolerated, increase to a final
rate to complete infusion in 60 minutes. If no infusion-related reactions occur, subsequent doses can be given over 60 minutes.
Incompatible with NS. Flush line with 50 mL D5W before and after infusion.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (DIFF if done locally),
Electrolytes, CA 125 (for ovarian, fallopian tube, and primary peritoneal cancer), Creatinine, Total Bilirubin, AST, ALT, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: liposomal DOXOrubicin and CARBOplatin for 210 minutes
Lab Only- Day 10, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Treatment Plan Summary
Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 days; COURSE: Until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 3 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 2 – 7/4/2017 through 7/31/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 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+28 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
For ovarian, fallopian tube, and primary peritoneal cancer
CREATININE
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 4 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 75K/µL or Total
Bilirubin greater than or equal to 1.2 mg/dL or AST or ALT greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to liposomal DOXOrubicin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of LIPOSOMAL doxorubicin and then every 30 minutes for
any subsequent doses.
Patient Instructions(1)
Liposomal DOXOrubicin: Educate patient about hand-foot syndrome and mucositis.
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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours before doxorubicin LIPOSOMAL to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
Pre-Medications
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to liposomal DOXOrubicin.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 5 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) 60 mg in dextrose 5 % 250 mL bag
60 mg (30 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Infuse first dose at a rate of 50 mL/hr for 15 minutes then increase to 100 mL/hr for 15 minutes and if tolerated, increase to a final
rate to complete infusion in 60 minutes. If no infusion-related reactions occur, subsequent doses can be given over 60 minutes.
Incompatible with NS. Flush line with 50 mL D5W before and after infusion.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (DIFF if done locally),
Electrolytes, CA 125 (for ovarian, fallopian tube, and primary peritoneal cancer), Creatinine, Total Bilirubin, AST, ALT, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: liposomal DOXOrubicin and CARBOplatin for 210 minutes
Lab Only- Day 10, Cycle 2 – Planned for 7/5/2017
Treatment Plan Information
Treatment Plan Summary
Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 days; COURSE: Until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 3 – 8/1/2017 through 8/28/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 6 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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+28 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
For ovarian, fallopian tube, and primary peritoneal cancer
CREATININE
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.2 mg/dL or AST or ALT greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to liposomal DOXOrubicin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of LIPOSOMAL doxorubicin and then every 30 minutes for
any subsequent doses.
Patient Instructions(1)
Liposomal DOXOrubicin: Educate patient about hand-foot syndrome and mucositis.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 7 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours before doxorubicin LIPOSOMAL to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
Pre-Medications
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to liposomal DOXOrubicin.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) 60 mg in dextrose 5 % 250 mL bag
60 mg (30 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Infuse first dose at a rate of 50 mL/hr for 15 minutes then increase to 100 mL/hr for 15 minutes and if tolerated, increase to a final
rate to complete infusion in 60 minutes. If no infusion-related reactions occur, subsequent doses can be given over 60 minutes.
Incompatible with NS. Flush line with 50 mL D5W before and after infusion.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (DIFF if done locally),
Electrolytes, CA 125 (for ovarian, fallopian tube, and primary peritoneal cancer), Creatinine, Total Bilirubin, AST, ALT, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: liposomal DOXOrubicin and CARBOplatin for 210 minutes
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 8 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Lab Only- Day 10, Cycle 3 – Planned for 8/2/2017
Treatment Plan Information
Treatment Plan Summary
Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 days; COURSE: Until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 4 – 8/29/2017 through 9/25/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 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+28 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
For ovarian, fallopian tube, and primary peritoneal cancer
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 9 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CREATININE
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.2 mg/dL or AST or ALT greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to liposomal DOXOrubicin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of LIPOSOMAL doxorubicin and then every 30 minutes for
any subsequent doses.
Patient Instructions(1)
Liposomal DOXOrubicin: Educate patient about hand-foot syndrome and mucositis.
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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours before doxorubicin LIPOSOMAL to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
Pre-Medications
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 10 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to liposomal DOXOrubicin.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) 60 mg in dextrose 5 % 250 mL bag
60 mg (30 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Infuse first dose at a rate of 50 mL/hr for 15 minutes then increase to 100 mL/hr for 15 minutes and if tolerated, increase to a final
rate to complete infusion in 60 minutes. If no infusion-related reactions occur, subsequent doses can be given over 60 minutes.
Incompatible with NS. Flush line with 50 mL D5W before and after infusion.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (DIFF if done locally),
Electrolytes, CA 125 (for ovarian, fallopian tube, and primary peritoneal cancer), Creatinine, Total Bilirubin, AST, ALT, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: liposomal DOXOrubicin and CARBOplatin for 210 minutes
Lab Only- Day 10, Cycle 4 – Planned for 8/30/2017
Treatment Plan Information
Treatment Plan Summary
Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 days; COURSE: Until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 11 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 5 – 9/26/2017 through 10/23/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 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+28 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
For ovarian, fallopian tube, and primary peritoneal cancer
CREATININE
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.2 mg/dL or AST or ALT greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 12 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hypersensitivity Monitoring (1)
Hypersensitivity reaction to liposomal DOXOrubicin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of LIPOSOMAL doxorubicin and then every 30 minutes for
any subsequent doses.
Patient Instructions(1)
Liposomal DOXOrubicin: Educate patient about hand-foot syndrome and mucositis.
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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours before doxorubicin LIPOSOMAL to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
Pre-Medications
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to liposomal DOXOrubicin.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) 60 mg in dextrose 5 % 250 mL bag
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 13 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

60 mg (30 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Hypersensitivity risk. See emergency medications.
Infuse first dose at a rate of 50 mL/hr for 15 minutes then increase to 100 mL/hr for 15 minutes and if tolerated,
increase to a final rate to complete infusion in 60 minutes. If no infusion-related reactions occur, subsequent doses
can be given over 60 minutes.
Incompatible with NS. Flush line with 50 mL D5W before and after infusion.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (DIFF if done locally),
Electrolytes, CA 125 (for ovarian, fallopian tube, and primary peritoneal cancer), Creatinine, Total Bilirubin, AST, ALT, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: liposomal DOXOrubicin and CARBOplatin for 210 minutes
Lab Only- Day 10, Cycle 5 – Planned for 9/27/2017
Treatment Plan Information
Treatment Plan Summary
Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 days; COURSE: Until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 6 – 10/24/2017 through 11/20/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 10/24/2017
Treatment Plan Information
Treatment Plan Summary
Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 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.
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 14 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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+28 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
For ovarian, fallopian tube, and primary peritoneal cancer
CREATININE
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 75K/µL or Total Bilirubin greater
than or equal to 1.2 mg/dL or AST or ALT greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to liposomal DOXOrubicin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of LIPOSOMAL doxorubicin and then every 30 minutes for
any subsequent doses.
Patient Instructions(1)
Liposomal DOXOrubicin: Educate patient about hand-foot syndrome and mucositis.
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 5:50:30 PM Page 15 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours before doxorubicin LIPOSOMAL to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
Pre-Medications
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to liposomal DOXOrubicin.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin LIPOSOMAL (DOXIL) 60 mg in dextrose 5 % 250 mL bag
60 mg (30 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Infuse first dose at a rate of 50 mL/hr for 15 minutes then increase to 100 mL/hr for 15 minutes and if tolerated, increase to a final
rate to complete infusion in 60 minutes. If no infusion-related reactions occur, subsequent doses can be given over 60 minutes.
Incompatible with NS. Flush line with 50 mL D5W before and after infusion.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (DIFF if done locally),
Electrolytes, CA 125 (for ovarian, fallopian tube, and primary peritoneal cancer), Creatinine, Total Bilirubin, AST, ALT, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: liposomal DOXOrubicin and CARBOplatin for 210 minutes
Lab Only- Day 10, Cycle 6 – Planned for 10/25/2017
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 16 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
Ovarian/Peritoneal/Fallopian Tube Cancer (Advanced): THERAPY: liposomal DOXOrubicin 30 mg/m2 IV Day 1, CARBOplatin
AUC=5 IV Day 1; CYCLE LENGTH: 28 days; COURSE: Until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
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Zztestonc,Edward E [2435061]
6/6/2017 5:50:30 PM Page 17 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org