/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-96759-en.cckm

201706157

page

100

UWHC,UWMF,

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

CSC GYN Gemcitabine(28D:1,8,15) VER 1-11-17 (HL 500)

CSC GYN Gemcitabine(28D:1,8,15) VER 1-11-17 (HL 500) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN GEMCITABINE(28D:1,8,15) VER: 1-11-17 – Properties
Pre-Cycle – 5/30/2017 through 6/5/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 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
CREATININE
Expected-S Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
CA 125
Expected-S Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer.
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 7/3/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
OVARIAN, PERITONEAL (PRIMARY), FALLOPIAN TUBE: Rose PG, et al. Int J Gynecol Cancer 2005;15:18-22.
Reference Information (2)
OVARIAN, PERITONEAL (PRIMARY), FALLOPIAN TUBE: Lund B, et al. J Natl Cancer Inst 1994;86:1530-3.
Reference Information (3)
UTERINE SARCOMA: Look KY, et al. Gynecol Oncol 2004;92:644-7.
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 1 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 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
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 22 FOLLOW-UP
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 2 of 26
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).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Potassium, Magnesium, AST, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes
Day 8, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 3 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 4 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22 - Lab only, Cycle 1 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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 – 7/4/2017 through 7/31/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Reference Information (1)
OVARIAN, PERITONEAL (PRIMARY), FALLOPIAN TUBE: Rose PG, et al. Int J Gynecol Cancer 2005;15:18-22.
Reference Information (2)
OVARIAN, PERITONEAL (PRIMARY), FALLOPIAN TUBE: Lund B, et al. J Natl Cancer Inst 1994;86:1530-3.
Reference Information (3)
UTERINE SARCOMA: Look KY, et al. Gynecol Oncol 2004;92:644-7.
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 5 of 26
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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
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
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 6 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 22 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Potassium, Magnesium, AST, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes
Day 8, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 7 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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 5:27:09 PM Page 8 of 26
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22 - Lab only, Cycle 2 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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 – 8/1/2017 through 8/28/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Reference Information (1)
OVARIAN, PERITONEAL (PRIMARY), FALLOPIAN TUBE: Rose PG, et al. Int J Gynecol Cancer 2005;15:18-22.
Reference Information (2)
OVARIAN, PERITONEAL (PRIMARY), FALLOPIAN TUBE: Lund B, et al. J Natl Cancer Inst 1994;86:1530-3.
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 9 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Reference Information (3)
UTERINE SARCOMA: Look KY, et al. Gynecol Oncol 2004;92:644-7.
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
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
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
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.
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 10 of 26
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 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 22 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Potassium, Magnesium, AST, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes
Day 8, Cycle 3 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 11 of 26
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 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 12 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22 - Lab only, Cycle 3 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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 5:27:09 PM Page 13 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Cycle 4 – 8/29/2017 through 9/25/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 8/29/2017
Treatment Plan Information
Reference Information (1)
OVARIAN, PERITONEAL (PRIMARY), FALLOPIAN TUBE: Rose PG, et al. Int J Gynecol Cancer 2005;15:18-22.
Reference Information (2)
OVARIAN, PERITONEAL (PRIMARY), FALLOPIAN TUBE: Lund B, et al. J Natl Cancer Inst 1994;86:1530-3.
Reference Information (3)
UTERINE SARCOMA: Look KY, et al. Gynecol Oncol 2004;92:644-7.
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
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
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 14 of 26
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 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 22 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Potassium, Magnesium, AST, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes
Day 8, Cycle 4 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 15 of 26
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 – Planned for 9/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 16 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22 - Lab only, Cycle 4 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 17 of 26
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 5 – 9/26/2017 through 10/23/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 9/26/2017
Treatment Plan Information
Reference Information (1)
OVARIAN, PERITONEAL (PRIMARY), FALLOPIAN TUBE: Rose PG, et al. Int J Gynecol Cancer 2005;15:18-22.
Reference Information (2)
OVARIAN, PERITONEAL (PRIMARY), FALLOPIAN TUBE: Lund B, et al. J Natl Cancer Inst 1994;86:1530-3.
Reference Information (3)
UTERINE SARCOMA: Look KY, et al. Gynecol Oncol 2004;92:644-7.
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
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
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 18 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 22 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Potassium, Magnesium, AST, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes
Day 8, Cycle 5 – Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 19 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical,
Vulvar, Vaginal (Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days;
COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 – Planned for 10/10/2017
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 20 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
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 5:27:09 PM Page 21 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Day 22 - Lab only, Cycle 5 – Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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 – 10/24/2017 through 11/20/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 10/24/2017
Treatment Plan Information
Reference Information (1)
OVARIAN, PERITONEAL (PRIMARY), FALLOPIAN TUBE: Rose PG, et al. Int J Gynecol Cancer 2005;15:18-22.
Reference Information (2)
OVARIAN, PERITONEAL (PRIMARY), FALLOPIAN TUBE: Lund B, et al. J Natl Cancer Inst 1994;86:1530-3.
Reference Information (3)
UTERINE SARCOMA: Look KY, et al. Gynecol Oncol 2004;92:644-7.
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 22 of 26
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
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Creatinine
greater than ULN.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 23 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DAY 22 FOLLOW-UP
LABS:CBC, ANC (DIFF if to be done locally).
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Potassium, Magnesium, AST, Total Bilirubin, CA-125; CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes
Day 8, Cycle 6 – Planned for 10/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 24 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 – Planned for 11/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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 8 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:27:09 PM Page 25 of 26
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
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
gemcitabine (GEMZAR) 2,000 mg in sodium chloride 0.9 % 100 mL bag
2,000 mg (1,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22 - Lab only, Cycle 6 – Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Peritoneal (Primary), Fallopian Tube (Advanced), Uterine Sarcoma (Advanced), Cervical, Vulvar, Vaginal
(Advanced); THERAPY: gemcitabine 1000 mg/m2 IV Days 1, 8 and 15; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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 5:27:09 PM Page 26 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org