/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-96749-en.cckm

201706157

page

100

UWHC,UWMF,

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

CSC GYN Cisplatin(21D:1) Doxorubicin(21D:1) VER 1-11-17 (HL 511)

CSC GYN Cisplatin(21D:1) Doxorubicin(21D:1) VER 1-11-17 (HL 511) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN CISPLATIN(21D:1)/DOXORUBICIN(21D;1) VER: 1-11-17 – Properties
Pre-Cycle – 5/30/2017 through 6/5/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Condition A
Verify patient has obtained pretreatment MUGA or ECHO.
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
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S, Local Printer
Cycle 1 – 6/6/2017 through 6/26/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
ENDOMETRIAL CANCER: Randall ME, et al. J Clin Oncol 2006;24:36-44.
Treatment Plan Summary
DISEASE: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
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Zztestonc,Edward E [2435061]
6/6/2017 5:29:32 PM Page 1 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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: WBC, ANC, Platelets, Creatinine, Total Bilirubin
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 or Total Bilirubin greater than or equal to 1.8 mg/dL
Treatment Condition A
Study Coordinator to verify a MUGA or ECHO has been done at baseline.
Nursing Procedure, Assessment and Monitoring
Measure Urine Output
SEE COMMENTS Starting when released Until Specified
Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
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% with KCl 20 mEq/L infusion
at 999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Administer over 1 hour prior to starting CISplatin infusion.
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
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 120 mg
120 mg (60 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). IV side arm push 3-5 mL/minute into running IV.
CISplatin (PLATINOL) 100 mg in sodium chloride 0.9 % 1,000 mL bag
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
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Zztestonc,Edward E [2435061]
6/6/2017 5:29:32 PM Page 2 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and CISplatin for 240 minutes.
Day 10 - Lab only, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 6/27/2017 through 7/17/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+21 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 5:29:32 PM Page 3 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Creatinine, Total Bilirubin
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 or Total Bilirubin greater than or equal to 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
Measure Urine Output
SEE COMMENTS Starting when released Until Specified
Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
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% with KCl 20 mEq/L infusion
at 999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Administer over 1 hour prior to starting CISplatin infusion.
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
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 120 mg
120 mg (60 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). IV side arm push 3-5 mL/minute into running IV.
CISplatin (PLATINOL) 100 mg in sodium chloride 0.9 % 1,000 mL bag
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and CISplatin for 240 minutes.
Day 10 - Lab only, Cycle 2 – Planned for 7/6/2017
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Zztestonc,Edward E [2435061]
6/6/2017 5:29:32 PM Page 4 of 12
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: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 7/18/2017 through 8/7/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+21 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Edward E [2435061]
6/6/2017 5:29:32 PM Page 5 of 12
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: WBC, ANC, Platelets, Creatinine, Total Bilirubin
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 or Total Bilirubin greater than or equal to 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
Measure Urine Output
SEE COMMENTS Starting when released Until Specified
Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
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% with KCl 20 mEq/L infusion
at 999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Administer over 1 hour prior to starting CISplatin infusion.
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
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 120 mg
120 mg (60 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). IV side arm push 3-5 mL/minute into running IV.
CISplatin (PLATINOL) 100 mg in sodium chloride 0.9 % 1,000 mL bag
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and CISplatin for 240 minutes.
Day 10 - Lab only, Cycle 3 – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
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Zztestonc,Edward E [2435061]
6/6/2017 5:29:32 PM Page 6 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 8/8/2017 through 8/28/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+21 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Creatinine, Total Bilirubin
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 or Total Bilirubin greater than or equal to 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Edward E [2435061]
6/6/2017 5:29:32 PM Page 7 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Measure Urine Output
SEE COMMENTS Starting when released Until Specified
Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
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% with KCl 20 mEq/L infusion
at 999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Administer over 1 hour prior to starting CISplatin infusion.
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
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 120 mg
120 mg (60 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). IV side arm push 3-5 mL/minute into running IV.
CISplatin (PLATINOL) 100 mg in sodium chloride 0.9 % 1,000 mL bag
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and CISplatin for 240 minutes.
Day 10 - Lab only, Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Edward E [2435061]
6/6/2017 5:29:32 PM Page 8 of 12
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 5 – 8/29/2017 through 9/18/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+21 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Creatinine, Total Bilirubin
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 or Total Bilirubin greater than or equal to 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
Measure Urine Output
SEE COMMENTS Starting when released Until Specified
Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Edward E [2435061]
6/6/2017 5:29:32 PM Page 9 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% with KCl 20 mEq/L infusion
at 999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Administer over 1 hour prior to starting CISplatin infusion.
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
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 120 mg
120 mg (60 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). IV side arm push 3-5 mL/minute into running IV.
CISplatin (PLATINOL) 100 mg in sodium chloride 0.9 % 1,000 mL bag
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and CISplatin for 240 minutes.
Day 10 - Lab only, Cycle 5 – Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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 5:29:32 PM Page 10 of 12
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 6 – 9/19/2017 through 10/9/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+21 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Creatinine, Total Bilirubin
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 or Total Bilirubin greater than or equal to 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
Measure Urine Output
SEE COMMENTS Starting when released Until Specified
Patient must void 500 mL prior to discharge. Notify MD if criteria not met.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Edward E [2435061]
6/6/2017 5:29:32 PM Page 11 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% with KCl 20 mEq/L infusion
at 999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Administer over 1 hour prior to starting CISplatin infusion.
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
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 120 mg
120 mg (60 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). IV side arm push 3-5 mL/minute into running IV.
CISplatin (PLATINOL) 100 mg in sodium chloride 0.9 % 1,000 mL bag
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and CISplatin for 240 minutes.
Day 10 - Lab only, Cycle 6 – Planned for 9/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Endometrial Cancer (Adjuvant/Advanced); THERAPY: doxorubicin 60 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1;
CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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 5:29:32 PM Page 12 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org