/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-96764-en.cckm

201706157

page

100

UWHC,UWMF,

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

CSC GYN INPT-OP EMA-EP (14D1,2 and 8) VER 1-11-17 (HL 4389)

CSC GYN INPT-OP EMA-EP (14D1,2 and 8) VER 1-11-17 (HL 4389) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN INPT/OP EMA-EP (14D:1,2, 8) VER: 1-11-17 – Properties
Cycle 1 – 6/6/2017 through 6/19/2017 (14 days), Planned
Day 1 and Day 2 Inpatient, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
GESTATIONAL TROPHOBLASTIC NEOPLASM (Adjuvant or Advanced): Newlands ES, et al. J Clin Oncol 2000;18:854-9
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and 2, etoposide 100 mg/m2 IV Day 1 and 2, methotrexate 100 mg/m2 IV push Day 1
followed by methotrexate 200 mg/m2 IV infusion over 12 hours Day 1, leucovorin 15 mg IV/PO every 12 hours for four doses starting
24 hours after the start of methotrexate infusion, etoposide 100 mg/m2 IV Day 8, CISplatin 75 mg/m2 IV Day 8; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued for 3 cycles past the first normal hCG level.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
POTASSIUM
ONCE Starting when released, Routine
MAGNESIUM
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
BUN
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC w/o DIFF, ANC, Potassium, Magnesium, Creatinine, BUN, Total Bilirubin, AST,
HCG
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL or Creatinine greater than ULN
Hydration
sodium chloride 0.9 % infusion 1,000 mL
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 1 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

at 500 mL/hr, Intravenous, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: 1000 mL Sodium Chloride 0.9% IV over 2 hours prior to chemotherapy.
sodium chloride 0.9 % infusion
at 125 mL/hr, Intravenous, CONTINUOUS, For 72 hours Starting when released
Day 1 and Day 2: Reduce infusion rate to 50 mL/hr while chemotherapy is infusing .
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting S+2 As Scheduled
Administer on Day 3, Day 4, and Day 5 if patient is not discharged after Day 2 doses of etoposide and dactinomycin.
Treatment Medications
DACTINOmycin (COSMOGEN) injection 500 mcg
500 mcg, Intravenous, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer IV push over 1-5 minutes into running IV.
etoposide (VEPESID) 200 mg in sodium chloride 0.9 % 500 mL NSS bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 2 doses Starting when
released
Day 1 and 2. Administer over 60 minutes. Administer with non-PVC tubing.
methotrexate PF 200 mg in dextrose 5 % 250 mL bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1, Administer over 30 minutes
methotrexate PF 400 mg in dextrose 5 % 250 mL bag
400 mg (200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1. Administer over 12 hours.
Treatment Medications (delete all that do not apply)
leucovorin tab 15 mg
15 mg, Oral, EVERY 12 HOURS, 4 doses Starting S+1 at 0000
Day 2: Administer every 12 hours for total of 4 doses, the first dose to be given 24 hours after the start of methotrexate infusion.
Patient may be discharged if tolerating oral intake well. If not tolerating oral intake well then may schedule IV Leucovorin in
Oncology Clinic.
leucovorin 20 MG/ML injection 15 mg
15 mg, Intravenous, EVERY 12 HOURS PRN, For 72 hours Starting S+1 at 0000, Administer over 3 Minutes
Day 2: Administer every 12 hours for total of 4 doses if patient unable to tolerate leucovorin orally. The first dose to be given 24
hours after the start of methotrexate infusion. Patient may be discharged if tolerating oral intake well. If not tolerating oral intake well
then may schedule IV Leucovorin in Oncology Clinic.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
IV push slowly, max rate 5 mg/minute.
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 2 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium, Creatinine, BUN, Total-Bilirubin, AST, ßHCG;
CHEMOTHERAPY ROOM APPOINTMENT: etoposide and CISplatin for 210 minutes.
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, BUN, Total Bilirubin, AST, ßHCG; CHEMOTHERAPY: Inpatient Admit per physicians discretion.
Day 8 Outpatient, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and 2, etoposide 100 mg/m2 IV Day 1 and 2, methotrexate 100 mg/m2 IV push Day 1
followed by methotrexate 200 mg/m2 IV infusion over 12 hours Day 1, leucovorin 15 mg IV/PO every 12 hours for four doses starting
24 hours after the start of methotrexate infusion, etoposide 100 mg/m2 IV Day 8, CISplatin 75 mg/m2 IV Day 8; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued for 3 cycles past the first normal hCG level.
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
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC w/o DIFF, ANC, Potassium, Magnesium, Creatinine, BUN, Total Bilirubin, AST,
HCG
Treatment Parameters
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 3 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 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
etoposide (VEPESID) 200 mg in sodium chloride 0.9 % 500 mL NSS bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 45 minutes. Administer with non-PVC tubing.
CISplatin (PLATINOL) 150 mg in sodium chloride 0.9 % 1,000 mL bag
150 mg (75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes.
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for two days following chemotherapy., 80 mg, Disp-2 cap, R-5, 1 X DAILY starting S,
Local Printer
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 2 days following chemotherapy, 8 mg, Disp-24 tab, R-5, 1 X DAILY starting S, Local
Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab 2x daily on Day 3 and 4 and Day 9 and 10. May take 1 tab every 8h as needed for nausea on other days, Disp-30 tab,
R-5, starting S
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 6/20/2017 through 7/3/2017 (14 days), Planned
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 4 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Day 1 and Day 2 Inpatient, Cycle 2 – Planned for 6/20/2017
Treatment Plan Information
Reference Information (1)
GESTATIONAL TROPHOBLASTIC NEOPLASM (Adjuvant or Advanced): Newlands ES, et al. J Clin Oncol 2000;18:854-9
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and 2, etoposide 100 mg/m2 IV Day 1 and 2, methotrexate 100 mg/m2 IV push Day 1
followed by methotrexate 200 mg/m2 IV infusion over 12 hours Day 1, leucovorin 15 mg IV/PO every 12 hours for four doses starting
24 hours after the start of methotrexate infusion, etoposide 100 mg/m2 IV Day 8, CISplatin 75 mg/m2 IV Day 8; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued for 3 cycles past the first normal hCG level.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
POTASSIUM
ONCE Starting when released, Routine
MAGNESIUM
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
BUN
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC w/o DIFF, ANC, Potassium, Magnesium, Creatinine, BUN, Total Bilirubin, AST,
HCG
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL or Creatinine greater than ULN
Hydration
sodium chloride 0.9 % infusion 1,000 mL
at 500 mL/hr, Intravenous, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: 1000 mL Sodium Chloride 0.9% IV over 2 hours prior to chemotherapy.
sodium chloride 0.9 % infusion
at 125 mL/hr, Intravenous, CONTINUOUS, For 72 hours Starting when released
Day 1 and Day 2: Reduce infusion rate to 50 mL/hr while chemotherapy is infusing .
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 5 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting S+2 As Scheduled
Administer on Day 3, Day 4, and Day 5 if patient is not discharged after Day 2 doses of etoposide and dactinomycin.
Treatment Medications
DACTINOmycin (COSMOGEN) injection 500 mcg
500 mcg, Intravenous, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer IV push over 1-5 minutes into running IV.
etoposide (VEPESID) 200 mg in sodium chloride 0.9 % 500 mL NSS bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 2 doses Starting when
released
Day 1 and 2. Administer over 60 minutes. Administer with non-PVC tubing.
methotrexate PF 200 mg in dextrose 5 % 250 mL bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1, Administer over 30 minutes
methotrexate PF 400 mg in dextrose 5 % 250 mL bag
400 mg (200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1. Administer over 12 hours.
Treatment Medications (delete all that do not apply)
leucovorin tab 15 mg
15 mg, Oral, EVERY 12 HOURS, 4 doses Starting S+1 at 0000
Day 2: Administer every 12 hours for total of 4 doses, the first dose to be given 24 hours after the start of methotrexate infusion.
Patient may be discharged if tolerating oral intake well. If not tolerating oral intake well then may schedule IV Leucovorin in
Oncology Clinic.
leucovorin 20 MG/ML injection 15 mg
15 mg, Intravenous, EVERY 12 HOURS PRN, For 72 hours Starting S+1 at 0000, Administer over 3 Minutes
Day 2: Administer every 12 hours for total of 4 doses if patient unable to tolerate leucovorin orally. The first dose to be given 24
hours after the start of methotrexate infusion. Patient may be discharged if tolerating oral intake well. If not tolerating oral intake well
then may schedule IV Leucovorin in Oncology Clinic.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
IV push slowly, max rate 5 mg/minute.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium, Creatinine, BUN, Total-Bilirubin, AST, ßHCG;
CHEMOTHERAPY ROOM APPOINTMENT: etoposide and CISplatin for 210 minutes.
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, BUN, Total Bilirubin, AST, ßHCG; CHEMOTHERAPY: Inpatient Admit per physicians discretion.
Day 8 Outpatient, Cycle 2 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 6 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and 2, etoposide 100 mg/m2 IV Day 1 and 2, methotrexate 100 mg/m2
IV push Day 1 followed by methotrexate 200 mg/m2 IV infusion over 12 hours Day 1, leucovorin 15 mg IV/PO every
12 hours for four doses starting 24 hours after the start of methotrexate infusion, etoposide 100 mg/m2 IV Day 8,
CISplatin 75 mg/m2 IV Day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment
continued for 3 cycles past the first normal hCG level.
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
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC w/o DIFF, ANC, Potassium, Magnesium, Creatinine, BUN, Total Bilirubin, AST,
HCG
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 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.
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 7 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
etoposide (VEPESID) 200 mg in sodium chloride 0.9 % 500 mL NSS bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 45 minutes. Administer with non-PVC tubing.
CISplatin (PLATINOL) 150 mg in sodium chloride 0.9 % 1,000 mL bag
150 mg (75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 7/4/2017 through 7/17/2017 (14 days), Planned
Day 1 and Day 2 Inpatient, Cycle 3 – Planned for 7/4/2017
Treatment Plan Information
Reference Information (1)
GESTATIONAL TROPHOBLASTIC NEOPLASM (Adjuvant or Advanced): Newlands ES, et al. J Clin Oncol 2000;18:854-9
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and 2, etoposide 100 mg/m2 IV Day 1 and 2, methotrexate 100 mg/m2 IV push Day 1
followed by methotrexate 200 mg/m2 IV infusion over 12 hours Day 1, leucovorin 15 mg IV/PO every 12 hours for four doses starting
24 hours after the start of methotrexate infusion, etoposide 100 mg/m2 IV Day 8, CISplatin 75 mg/m2 IV Day 8; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued for 3 cycles past the first normal hCG level.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
POTASSIUM
ONCE Starting when released, Routine
MAGNESIUM
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
BUN
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 8 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC w/o DIFF, ANC, Potassium, Magnesium, Creatinine, BUN, Total Bilirubin, AST,
HCG
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL or Creatinine greater than ULN
Hydration
sodium chloride 0.9 % infusion 1,000 mL
at 500 mL/hr, Intravenous, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: 1000 mL Sodium Chloride 0.9% IV over 2 hours prior to chemotherapy.
sodium chloride 0.9 % infusion
at 125 mL/hr, Intravenous, CONTINUOUS, For 72 hours Starting when released
Day 1 and Day 2: Reduce infusion rate to 50 mL/hr while chemotherapy is infusing .
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting S+2 As Scheduled
Administer on Day 3, Day 4, and Day 5 if patient is not discharged after Day 2 doses of etoposide and dactinomycin.
Treatment Medications
DACTINOmycin (COSMOGEN) injection 500 mcg
500 mcg, Intravenous, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer IV push over 1-5 minutes into running IV.
etoposide (VEPESID) 200 mg in sodium chloride 0.9 % 500 mL NSS bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 2 doses Starting when
released
Day 1 and 2. Administer over 60 minutes. Administer with non-PVC tubing.
methotrexate PF 200 mg in dextrose 5 % 250 mL bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1, Administer over 30 minutes
methotrexate PF 400 mg in dextrose 5 % 250 mL bag
400 mg (200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1. Administer over 12 hours.
Treatment Medications (delete all that do not apply)
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 9 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

leucovorin tab 15 mg
15 mg, Oral, EVERY 12 HOURS, 4 doses Starting S+1 at 0000
Day 2: Administer every 12 hours for total of 4 doses, the first dose to be given 24 hours after the start of
methotrexate infusion. Patient may be discharged if tolerating oral intake well. If not tolerating oral intake well then
may schedule IV Leucovorin in Oncology Clinic.
leucovorin 20 MG/ML injection 15 mg
15 mg, Intravenous, EVERY 12 HOURS PRN, For 72 hours Starting S+1 at 0000, Administer over 3 Minutes
Day 2: Administer every 12 hours for total of 4 doses if patient unable to tolerate leucovorin orally. The first dose to be given 24
hours after the start of methotrexate infusion. Patient may be discharged if tolerating oral intake well. If not tolerating oral intake well
then may schedule IV Leucovorin in Oncology Clinic.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
IV push slowly, max rate 5 mg/minute.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium, Creatinine, BUN, Total-Bilirubin, AST, ßHCG;
CHEMOTHERAPY ROOM APPOINTMENT: etoposide and CISplatin for 210 minutes.
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, BUN, Total Bilirubin, AST, ßHCG; CHEMOTHERAPY: Inpatient Admit per physicians discretion.
Day 8 Outpatient, Cycle 3 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and 2, etoposide 100 mg/m2 IV Day 1 and 2, methotrexate 100 mg/m2 IV push Day 1
followed by methotrexate 200 mg/m2 IV infusion over 12 hours Day 1, leucovorin 15 mg IV/PO every 12 hours for four doses starting
24 hours after the start of methotrexate infusion, etoposide 100 mg/m2 IV Day 8, CISplatin 75 mg/m2 IV Day 8; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued for 3 cycles past the first normal hCG level.
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
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 10 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC w/o DIFF, ANC, Potassium, Magnesium, Creatinine, BUN, Total Bilirubin, AST,
HCG
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 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
etoposide (VEPESID) 200 mg in sodium chloride 0.9 % 500 mL NSS bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 45 minutes. Administer with non-PVC tubing.
CISplatin (PLATINOL) 150 mg in sodium chloride 0.9 % 1,000 mL bag
150 mg (75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 7/18/2017 through 7/31/2017 (14 days), Planned
Day 1 and Day 2 Inpatient, Cycle 4 – Planned for 7/18/2017
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 11 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
GESTATIONAL TROPHOBLASTIC NEOPLASM (Adjuvant or Advanced): Newlands ES, et al. J Clin Oncol 2000;18:854-9
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and 2, etoposide 100 mg/m2 IV Day 1 and 2, methotrexate 100 mg/m2 IV push Day 1
followed by methotrexate 200 mg/m2 IV infusion over 12 hours Day 1, leucovorin 15 mg IV/PO every 12 hours for four doses starting
24 hours after the start of methotrexate infusion, etoposide 100 mg/m2 IV Day 8, CISplatin 75 mg/m2 IV Day 8; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued for 3 cycles past the first normal hCG level.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
POTASSIUM
ONCE Starting when released, Routine
MAGNESIUM
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
BUN
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC w/o DIFF, ANC, Potassium, Magnesium, Creatinine, BUN, Total Bilirubin, AST,
HCG
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL or Creatinine greater than ULN
Hydration
sodium chloride 0.9 % infusion 1,000 mL
at 500 mL/hr, Intravenous, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: 1000 mL Sodium Chloride 0.9% IV over 2 hours prior to chemotherapy.
sodium chloride 0.9 % infusion
at 125 mL/hr, Intravenous, CONTINUOUS, For 72 hours Starting when released
Day 1 and Day 2: Reduce infusion rate to 50 mL/hr while chemotherapy is infusing .
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 12 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

16 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting S+2 As Scheduled
Administer on Day 3, Day 4, and Day 5 if patient is not discharged after Day 2 doses of etoposide and dactinomycin.
Treatment Medications
DACTINOmycin (COSMOGEN) injection 500 mcg
500 mcg, Intravenous, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer IV push over 1-5 minutes into running IV.
etoposide (VEPESID) 200 mg in sodium chloride 0.9 % 500 mL NSS bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 2 doses Starting when
released
Day 1 and 2. Administer over 60 minutes. Administer with non-PVC tubing.
methotrexate PF 200 mg in dextrose 5 % 250 mL bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1, Administer over 30 minutes
methotrexate PF 400 mg in dextrose 5 % 250 mL bag
400 mg (200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1. Administer over 12 hours.
Treatment Medications (delete all that do not apply)
leucovorin tab 15 mg
15 mg, Oral, EVERY 12 HOURS, 4 doses Starting S+1 at 0000
Day 2: Administer every 12 hours for total of 4 doses, the first dose to be given 24 hours after the start of methotrexate infusion.
Patient may be discharged if tolerating oral intake well. If not tolerating oral intake well then may schedule IV Leucovorin in
Oncology Clinic.
leucovorin 20 MG/ML injection 15 mg
15 mg, Intravenous, EVERY 12 HOURS PRN, For 72 hours Starting S+1 at 0000, Administer over 3 Minutes
Day 2: Administer every 12 hours for total of 4 doses if patient unable to tolerate leucovorin orally. The first dose to be given 24
hours after the start of methotrexate infusion. Patient may be discharged if tolerating oral intake well. If not tolerating oral intake well
then may schedule IV Leucovorin in Oncology Clinic.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
IV push slowly, max rate 5 mg/minute.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium, Creatinine, BUN, Total-Bilirubin, AST, ßHCG;
CHEMOTHERAPY ROOM APPOINTMENT: etoposide and CISplatin for 210 minutes.
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, BUN, Total Bilirubin, AST, ßHCG; CHEMOTHERAPY: Inpatient Admit per physicians discretion.
Day 8 Outpatient, Cycle 4 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 13 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and 2, etoposide 100 mg/m2 IV Day 1 and 2, methotrexate 100 mg/m2 IV push Day 1
followed by methotrexate 200 mg/m2 IV infusion over 12 hours Day 1, leucovorin 15 mg IV/PO every 12 hours for four doses starting
24 hours after the start of methotrexate infusion, etoposide 100 mg/m2 IV Day 8, CISplatin 75 mg/m2 IV Day 8; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued for 3 cycles past the first normal hCG level.
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
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC w/o DIFF, ANC, Potassium, Magnesium, Creatinine, BUN, Total Bilirubin, AST,
HCG
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 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
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 14 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
etoposide (VEPESID) 200 mg in sodium chloride 0.9 % 500 mL NSS bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 45 minutes. Administer with non-PVC tubing.
CISplatin (PLATINOL) 150 mg in sodium chloride 0.9 % 1,000 mL bag
150 mg (75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 8/1/2017 through 8/14/2017 (14 days), Planned
Day 1 and Day 2 Inpatient, Cycle 5 – Planned for 8/1/2017
Treatment Plan Information
Reference Information (1)
GESTATIONAL TROPHOBLASTIC NEOPLASM (Adjuvant or Advanced): Newlands ES, et al. J Clin Oncol 2000;18:854-9
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and 2, etoposide 100 mg/m2 IV Day 1 and 2, methotrexate 100 mg/m2 IV push Day 1
followed by methotrexate 200 mg/m2 IV infusion over 12 hours Day 1, leucovorin 15 mg IV/PO every 12 hours for four doses starting
24 hours after the start of methotrexate infusion, etoposide 100 mg/m2 IV Day 8, CISplatin 75 mg/m2 IV Day 8; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued for 3 cycles past the first normal hCG level.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
POTASSIUM
ONCE Starting when released, Routine
MAGNESIUM
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
BUN
ONCE Starting when released
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 15 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC w/o DIFF, ANC, Potassium, Magnesium, Creatinine, BUN, Total Bilirubin, AST,
HCG
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL or Creatinine greater than ULN
Hydration
sodium chloride 0.9 % infusion 1,000 mL
at 500 mL/hr, Intravenous, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: 1000 mL Sodium Chloride 0.9% IV over 2 hours prior to chemotherapy.
sodium chloride 0.9 % infusion
at 125 mL/hr, Intravenous, CONTINUOUS, For 72 hours Starting when released
Day 1 and Day 2: Reduce infusion rate to 50 mL/hr while chemotherapy is infusing .
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting S+2 As Scheduled
Administer on Day 3, Day 4, and Day 5 if patient is not discharged after Day 2 doses of etoposide and dactinomycin.
Treatment Medications
DACTINOmycin (COSMOGEN) injection 500 mcg
500 mcg, Intravenous, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer IV push over 1-5 minutes into running IV.
etoposide (VEPESID) 200 mg in sodium chloride 0.9 % 500 mL NSS bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 2 doses Starting when
released
Day 1 and 2. Administer over 60 minutes. Administer with non-PVC tubing.
methotrexate PF 200 mg in dextrose 5 % 250 mL bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1, Administer over 30 minutes
methotrexate PF 400 mg in dextrose 5 % 250 mL bag
400 mg (200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1. Administer over 12 hours.
Treatment Medications (delete all that do not apply)
leucovorin tab 15 mg
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 16 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

15 mg, Oral, EVERY 12 HOURS, 4 doses Starting S+1 at 0000
Day 2: Administer every 12 hours for total of 4 doses, the first dose to be given 24 hours after the start of methotrexate infusion.
Patient may be discharged if tolerating oral intake well. If not tolerating oral intake well then may schedule IV Leucovorin in
Oncology Clinic.
leucovorin 20 MG/ML injection 15 mg
15 mg, Intravenous, EVERY 12 HOURS PRN, For 72 hours Starting S+1 at 0000, Administer over 3 Minutes
Day 2: Administer every 12 hours for total of 4 doses if patient unable to tolerate leucovorin orally. The first dose to be given 24
hours after the start of methotrexate infusion. Patient may be discharged if tolerating oral intake well. If not tolerating oral intake well
then may schedule IV Leucovorin in Oncology Clinic.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
IV push slowly, max rate 5 mg/minute.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium, Creatinine, BUN, Total-Bilirubin, AST, ßHCG;
CHEMOTHERAPY ROOM APPOINTMENT: etoposide and CISplatin for 210 minutes.
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, BUN, Total Bilirubin, AST, ßHCG; CHEMOTHERAPY: Inpatient Admit per physicians discretion.
Day 8 Outpatient, Cycle 5 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and 2, etoposide 100 mg/m2 IV Day 1 and 2, methotrexate 100 mg/m2 IV push Day 1
followed by methotrexate 200 mg/m2 IV infusion over 12 hours Day 1, leucovorin 15 mg IV/PO every 12 hours for four doses starting
24 hours after the start of methotrexate infusion, etoposide 100 mg/m2 IV Day 8, CISplatin 75 mg/m2 IV Day 8; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued for 3 cycles past the first normal hCG level.
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
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 17 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

HCG, QUANTITATIVE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC w/o DIFF, ANC, Potassium, Magnesium, Creatinine, BUN, Total Bilirubin, AST,
HCG
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 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
etoposide (VEPESID) 200 mg in sodium chloride 0.9 % 500 mL NSS bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 45 minutes. Administer with non-PVC tubing.
CISplatin (PLATINOL) 150 mg in sodium chloride 0.9 % 1,000 mL bag
150 mg (75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 8/15/2017 through 8/28/2017 (14 days), Planned
Day 1 and Day 2 Inpatient, Cycle 6 – Planned for 8/15/2017
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 18 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
GESTATIONAL TROPHOBLASTIC NEOPLASM (Adjuvant or Advanced): Newlands ES, et al. J Clin Oncol 2000;18:854-9
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and 2, etoposide 100 mg/m2 IV Day 1 and 2, methotrexate 100 mg/m2 IV push Day 1
followed by methotrexate 200 mg/m2 IV infusion over 12 hours Day 1, leucovorin 15 mg IV/PO every 12 hours for four doses starting
24 hours after the start of methotrexate infusion, etoposide 100 mg/m2 IV Day 8, CISplatin 75 mg/m2 IV Day 8; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued for 3 cycles past the first normal hCG level.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
POTASSIUM
ONCE Starting when released, Routine
MAGNESIUM
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
BUN
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC w/o DIFF, ANC, Potassium, Magnesium, Creatinine, BUN, Total Bilirubin, AST,
HCG
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL or Creatinine greater than ULN
Hydration
sodium chloride 0.9 % infusion 1,000 mL
at 500 mL/hr, Intravenous, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: 1000 mL Sodium Chloride 0.9% IV over 2 hours prior to chemotherapy.
sodium chloride 0.9 % infusion
at 125 mL/hr, Intravenous, CONTINUOUS, For 72 hours Starting when released
Day 1 and Day 2: Reduce infusion rate to 50 mL/hr while chemotherapy is infusing .
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 19 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

16 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting S+2 As Scheduled
Administer on Day 3, Day 4, and Day 5 if patient is not discharged after Day 2 doses of etoposide and dactinomycin.
Treatment Medications
DACTINOmycin (COSMOGEN) injection 500 mcg
500 mcg, Intravenous, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer IV push over 1-5 minutes into running IV.
etoposide (VEPESID) 200 mg in sodium chloride 0.9 % 500 mL NSS bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 2 doses Starting when
released
Day 1 and 2. Administer over 60 minutes. Administer with non-PVC tubing.
methotrexate PF 200 mg in dextrose 5 % 250 mL bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1, Administer over 30 minutes
methotrexate PF 400 mg in dextrose 5 % 250 mL bag
400 mg (200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1. Administer over 12 hours.
Treatment Medications (delete all that do not apply)
leucovorin tab 15 mg
15 mg, Oral, EVERY 12 HOURS, 4 doses Starting S+1 at 0000
Day 2: Administer every 12 hours for total of 4 doses, the first dose to be given 24 hours after the start of methotrexate infusion.
Patient may be discharged if tolerating oral intake well. If not tolerating oral intake well then may schedule IV Leucovorin in
Oncology Clinic.
leucovorin 20 MG/ML injection 15 mg
15 mg, Intravenous, EVERY 12 HOURS PRN, For 72 hours Starting S+1 at 0000, Administer over 3 Minutes
Day 2: Administer every 12 hours for total of 4 doses if patient unable to tolerate leucovorin orally. The first dose to be given 24
hours after the start of methotrexate infusion. Patient may be discharged if tolerating oral intake well. If not tolerating oral intake well
then may schedule IV Leucovorin in Oncology Clinic.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
IV push slowly, max rate 5 mg/minute.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Potassium, Magnesium, Creatinine, BUN, Total-Bilirubin, AST, ßHCG;
CHEMOTHERAPY ROOM APPOINTMENT: etoposide and CISplatin for 210 minutes.
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Potassium,
Magnesium, Creatinine, BUN, Total Bilirubin, AST, ßHCG; CHEMOTHERAPY: Inpatient Admit per physicians discretion.
Day 8 Outpatient, Cycle 6 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 20 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and 2, etoposide 100 mg/m2 IV Day 1 and 2, methotrexate 100 mg/m2 IV push Day 1
followed by methotrexate 200 mg/m2 IV infusion over 12 hours Day 1, leucovorin 15 mg IV/PO every 12 hours for four doses starting
24 hours after the start of methotrexate infusion, etoposide 100 mg/m2 IV Day 8, CISplatin 75 mg/m2 IV Day 8; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued for 3 cycles past the first normal hCG level.
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
POTASSIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC w/o DIFF, ANC, Potassium, Magnesium, Creatinine, BUN, Total Bilirubin, AST,
HCG
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 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
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Zztestonc,Edward E [2435061]
6/6/2017 6:05:06 PM Page 21 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
etoposide (VEPESID) 200 mg in sodium chloride 0.9 % 500 mL NSS bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 45 minutes. Administer with non-PVC tubing.
CISplatin (PLATINOL) 150 mg in sodium chloride 0.9 % 1,000 mL bag
150 mg (75 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes.
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 6:05:06 PM Page 22 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org