/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-96747-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 Cyclophosphamide(28D:1) VER 1-11-17 (HL 494)

CSC GYN Carboplatin Cyclophosphamide(28D:1) VER 1-11-17 (HL 494) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN CARBOPLATIN/CYCLOPHOSPHAMIDE(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
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S, Expires-S+365, Routine
POTASSIUM
Expected-S, Expires-S+365, Routine
CA 125
Expected-S, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S, Expires-S+365, Routine
CREATININE
Expected-S, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following chemotherapy., 80 mg, Disp-2 cap, R-5, 1 X DAILY starting S
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-24 tab, R-5, 1 X DAILY starting S, Local
Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 6/6/2017 through 7/3/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
OVARIAN, PRIMARY PERITONEAL, FALLOPIAN TUBE: Alberts DS, et al. J Clin Oncol 1992;10:706-17.
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 1 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 2 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
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.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/4/2017 through 7/31/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
Note to All Staff (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 3 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CA 125
Expected-S+28 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 4 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
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.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 2 – Planned for 7/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 5 of 19
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 – 8/1/2017 through 8/28/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CA 125
Expected-S+28 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 6 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
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.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 3 – Planned for 8/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 7 of 19
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 8/29/2017 through 9/25/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CA 125
Expected-S+28 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 8 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
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.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 9 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 4 – Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 9/26/2017 through 10/23/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
POTASSIUM
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 10 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+365, Routine
CA 125
Expected-S+28 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 11 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
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.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 5 – Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 10/24/2017 through 11/20/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 10/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 12 of 19
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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CA 125
Expected-S+28 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 13 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
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.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 6 – Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 11/21/2017 through 12/18/2017 (28 days), Planned
Day 1, Cycle 7 – Planned for 11/21/2017
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 14 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CA 125
Expected-S+28 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 15 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
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.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 7 – Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 16 of 19
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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 12/19/2017 through 1/15/2018 (28 days), Planned
Day 1, Cycle 8 – Planned for 12/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
Note to All Staff (1)
If patient develops hypersensitivity to CARBOplatin the UWCCC CARBOplatin Desensitization Protocol may be utilized. The
CARBOplatin Desensitization Protocol is a supportive care plan that should be utilized in conjunction with the patient's current
treatment plan. DO NOT DISCONTINUE THE CURRENT TREATMENT PLAN.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CA 125
Expected-S+28 Approximate, Expires-S+365, Routine
For Ovarian Cancer only.
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 17 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
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.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and CARBOplatin for 150 minutes.
Lab Only - Day 10, Cycle 8 – Planned for 12/28/2017
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 18 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian (Advanced/Adjuvant). THERAPY: cyclophosphamide 600 mg/m2 IV Day 1,
CARBOplatin (AUC=5 to 7.5) IV Day 1; CYCLE LENGTH: 28 days. COURSE: 6 to 8 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Edward E [2435061]
6/6/2017 5:17:41 PM Page 19 of 19
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org