/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-96750-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) Topotecan(21D:1-3) VER 1-11-17 (HL 510)

CSC GYN Cisplatin(21D:1) Topotecan(21D:1-3) VER 1-11-17 (HL 510) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN CISPLATIN(21D:1)/TOPOTECAN(21D:1-3) 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: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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
Take Home Medications
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 6/26/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
CERVICAL, VULVAR, VAGINAL CANCER: Long HJ 3rd, et al. J Clin Onc 2005;23(21):4626-33
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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.
Treatment Conditions
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 1 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
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
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.
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (differential 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; CHEMOTHERAPY ROOM APPOINTMENT:CISplatin and topotecan for 180 minutes.
Day 2, Cycle 1 – Planned for 6/7/2017
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 2 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 – Planned for 6/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 3 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 6/27/2017 through 7/17/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 6/27/2017
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 4 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 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
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.
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 5 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
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
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.
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (differential 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; CHEMOTHERAPY ROOM APPOINTMENT:CISplatin and topotecan for 180 minutes.
Day 2, Cycle 2 – Planned for 6/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 6 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 2 – Planned for 6/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 7 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 2 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 7/18/2017 through 8/7/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 8 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CREATININE
Expected-S+19 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
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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
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
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.
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (differential if to be done locally)
DAY 22 FOLLOW-UP
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 9 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine; CHEMOTHERAPY ROOM APPOINTMENT:CISplatin and topotecan for 180 minutes.
Day 2, Cycle 3 – Planned for 7/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 3 – Planned for 7/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 10 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 3 – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 11 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 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
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.
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 12 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
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
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.
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (differential 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; CHEMOTHERAPY ROOM APPOINTMENT:CISplatin and topotecan for 180 minutes.
Day 2, Cycle 4 – Planned for 8/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 13 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 – Planned for 8/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 14 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 8/29/2017 through 9/18/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
POTASSIUM
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 15 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 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
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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
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
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.
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 16 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DAY 10 FOLLOW-UP
LABS: CBC, ANC (differential 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; CHEMOTHERAPY ROOM APPOINTMENT:CISplatin and topotecan for 180 minutes.
Day 2, Cycle 5 – Planned for 8/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 5 – Planned for 8/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; CYCLE LENGTH: 21 days; COURSE: until disease progression.
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 17 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 5 – Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 18 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 9/19/2017 through 10/9/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 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
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 19 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
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
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.
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan for 60 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (differential 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; CHEMOTHERAPY ROOM APPOINTMENT:CISplatin and topotecan for 180 minutes.
Day 2, Cycle 6 – Planned for 9/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 20 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 6 – Planned for 9/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; 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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 21 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
topotecan (HYCAMTIN) 1.5 mg in sodium chloride 0.9 % 100 mL bag
1.5 mg (0.75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 6 – Planned for 9/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: CISplatin 50 mg/m2 IV Day 1, topotecan 0.75 mg/m2
IV Days 1, 2 and 3; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Edward E [2435061]
6/6/2017 5:28:19 PM Page 22 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org