/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-96751-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:1,8) Gemcitabine(21D:1,8) VER 1-11-17 (HL 482)

CSC GYN Cisplatin(21D:1,8) Gemcitabine(21D:1,8) VER 1-11-17 (HL 482) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN CISPLATIN(21D:1,8)/GEMCITABINE(21D:1,8) 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: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
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
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)
CERVICAL, VULVAR, VAGINAL CANCER: Brewer CA, et al. Gynecol Oncol 2006;100(2):385-8.
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 1 of 20
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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
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
gemcitabine (GEMZAR) 1,600 mg in sodium chloride 0.9 % 100 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 60 mg in sodium chloride 0.9 % 1,000 mL bag
60 mg (30 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and
CISplatin for 150 minutes.
DAY 15 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),Creatinine,
Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and CISplatin for 150 minutes.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 2 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Day 8, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 3 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 1,600 mg in sodium chloride 0.9 % 100 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 60 mg in sodium chloride 0.9 % 1,000 mL bag
60 mg (30 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 15, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 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+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
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 4 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
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
gemcitabine (GEMZAR) 1,600 mg in sodium chloride 0.9 % 100 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 60 mg in sodium chloride 0.9 % 1,000 mL bag
60 mg (30 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 8 FOLLOW-UP
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 5 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT:
gemcitabine and CISplatin for 150 minutes.
DAY 15 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),Creatinine,
Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and CISplatin for 150 minutes.
Day 8, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 6 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
gemcitabine (GEMZAR) 1,600 mg in sodium chloride 0.9 % 100 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 60 mg in sodium chloride 0.9 % 1,000 mL bag
60 mg (30 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 15, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 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+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: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 7 of 20
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 8 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

gemcitabine (GEMZAR) 1,600 mg in sodium chloride 0.9 % 100 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 60 mg in sodium chloride 0.9 % 1,000 mL bag
60 mg (30 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and
CISplatin for 150 minutes.
DAY 15 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),Creatinine,
Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and CISplatin for 150 minutes.
Day 8, Cycle 3 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 9 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% 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
gemcitabine (GEMZAR) 1,600 mg in sodium chloride 0.9 % 100 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 60 mg in sodium chloride 0.9 % 1,000 mL bag
60 mg (30 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 15, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 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+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 4 – 8/8/2017 through 8/28/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/8/2017
Treatment Plan Information
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 10 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 11 of 20
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
Treatment Medications
gemcitabine (GEMZAR) 1,600 mg in sodium chloride 0.9 % 100 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 60 mg in sodium chloride 0.9 % 1,000 mL bag
60 mg (30 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and
CISplatin for 150 minutes.
DAY 15 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),Creatinine,
Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and CISplatin for 150 minutes.
Day 8, Cycle 4 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Measure Urine Output
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 12 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
gemcitabine (GEMZAR) 1,600 mg in sodium chloride 0.9 % 100 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 60 mg in sodium chloride 0.9 % 1,000 mL bag
60 mg (30 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 15, Cycle 4 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 13 of 20
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 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: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 14 of 20
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
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
gemcitabine (GEMZAR) 1,600 mg in sodium chloride 0.9 % 100 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 60 mg in sodium chloride 0.9 % 1,000 mL bag
60 mg (30 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and
CISplatin for 150 minutes.
DAY 15 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),Creatinine,
Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and CISplatin for 150 minutes.
Day 8, Cycle 5 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 15 of 20
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 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
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
gemcitabine (GEMZAR) 1,600 mg in sodium chloride 0.9 % 100 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 60 mg in sodium chloride 0.9 % 1,000 mL bag
60 mg (30 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 15, Cycle 5 – Planned for 9/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 16 of 20
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.
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 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: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 17 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% 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
gemcitabine (GEMZAR) 1,600 mg in sodium chloride 0.9 % 100 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 60 mg in sodium chloride 0.9 % 1,000 mL bag
60 mg (30 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and
CISplatin for 150 minutes.
DAY 15 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),Creatinine,
Potassium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine and CISplatin for 150 minutes.
Day 8, Cycle 6 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical, Vulvar, Vaginal Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 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+7 Approximate, Expires-S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 18 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
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
gemcitabine (GEMZAR) 1,600 mg in sodium chloride 0.9 % 100 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CISplatin (PLATINOL) 60 mg in sodium chloride 0.9 % 1,000 mL bag
60 mg (30 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 15, Cycle 6 – Planned for 10/3/2017
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 19 of 20
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: gemcitabine 800 mg/m2 IV on Day 1 and 8, CISplatin
30 mg/m2 IV on Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 4 to 6 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+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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:14:21 PM Page 20 of 20
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org